


^- 









j.*^>.^-, -^ ^^^ 



'^,% 



^^ v^^ 



^' % -.;^^^^*r ^ ^^ 



. >^ ^ ^ * ^' 






^^- .vV' 









-0^ 






^\^0^ 



.^^ '^. 



^^ A 



*-^ ^*. 



-x\^ 






-^^ 






V <P, 



r '^. 










-0 



cP' 



-V C' 



X^" 



.>^ -^^ 



.^" '^^ 



X -f- 



•''^y- v^^^ 









o. 



....o.._, .. .<y ,. .. ^ ? .■ckT" . 







^0 

Li 



U 


















^' :/ 



^J- .^^ 






^^^v^^ 

^^%. 

./ ^ 






THE 



Diseases of Children 



AND THEIR 



HOMEOPATHIC TREATMENT. 



A Text-Book for Students, Colleges, and Practitioner 



ROBERT N. TOOKER, M.D., 

Prfoessor of Diseases of Children in the Chicago Homeopathic Medical College; Ex- 
President of the American Pedological Association; Ex-President of the Illinois 
Association of Homeopathic Physicians ; Ex-President of the Chicago 
Academy of Homeopathic Physicians and Surgeons ; Ex- 
Chairman of the Bureau of Pedology of the 
American Institute, etc., etc. 






CHICAGO 

GROSS AND DELBRIDGE 

No. 48 Madison Street 
i8q; 



^ \ 



<p^ 






Copyright, 1894, 
GROSS & DELBRIDGE. 



TO 

MARIA M. GROSS, M. D. 

WHO WAS AMONG THE FIRST OF HER SEX TO 

DEMONSTRATE WOMAN's FITNESS 

FOR THE STUDY AND PRACTICE OF MEDICINE, AND WHOSE 

ADVICE AND COUNSEL 

HAVE OFTEN BEEN OF GREAT VALUE TO THE WRITER 

IN CRITICAL CASES, THIS 

WORK IS AFFECTIONATELY DEDICATED KY 

HER BROTHER, 

THE AUTHOR. 



Uii) 



PREFACE. 



The need of a new and comprehensive treatise on Pediatrics, 
adapted to the wants of students and practitioners of the 
Homeopathic School of Medicine, has long been recognized. 
The literature of the older school is replete with manuals of 
the highest order, and cyclopedias of rare merit ; but our own is 
almost barren in this direction. In every other branch of medi- 
cine and surgery, our authors have been numerous and prolific. 

In Pediatrics alone, are we behind our confreres. This state 
of affairs cannot be explained on the ground of indifference, or 
in any way satisfactorily, except that our many able writers in 
this specialty, have each been waiting for the other to take the 
initiative and assume the burden and responsibility of author- 
ship. The writer began the preparation of the present volume 
more than five years ago, but its progress was suspended for 
several years, owing to current rumors that others quite as 
capable were actively engaged in a similar undertaking. As 
these rumors failed to materialize, the demand for a new book 
on the diseases of children and their homeopathic treatment, 
became imperative, and the work was resumed. 

The labor involved in the preparation of an acceptable trea- 
tise, covering the entire field of Pedology, seemed, at first, to be 
prohibitory, in the midst of a busy every-day practice, and the 
exacting duties of college work ; but the enthusiastic proffers of 
aid from so many professional friends, who had already become 
widely known as authors and teachers, gave all needed encour- 
agement, and the work has, with their help, been carried to 
completion in a most agreeable manner. The author's thanks 
are hereby given to Prof. L. C. Grosvenor, for his chapter on 
the Sanitation of the Nursery ; to Prof. J. H. Buffum, for the 
chapters on the Eye and Ear; to Prof. E. M. Hale — Affections 

(V) 



PRE FA CE. 

of the Heart ; and to Prof. Clifford Mitchell, for his admirable 
contribution on the Disorders of the Urinary Tract. 

Thanks are also due to Profs. N. B. Delamater and S. N. 
Schneider for the section on Nervous diseases. 

Finally, the author desires to express his obligations to the 
numerous writers of both schools of medicine, whose contribu- 
tions to the literature of this subject have been constantly con- 
sulted, and at times freely drawn upon, due credit being given 
in the text as called for. 

The diseases of children are practically the same the world 
over, and they have been so often, so accurately, and exhaus- 
tively described, that a distinctively original work on Pedology 
is scarcely possible. 

The aim of the writer has been, not so much to improve on, or 
vary the descriptions of, disease phenomena, affecting infants 
and children, as set forth in other and standard treatises ; nor 
to add to, or find fault with, accepted theories of etiology and 
pathology, but rather to condense our present knowledge, 
opinions, and theories, and gather together the best therapeu- 
tic and hygienic measures for the relief of infantile maladies. 

That portion of the work for which the writer is more espe- 
cially responsible, is the outgrowth of thirty years' experience 
as a medical practitioner, more than half of which period has 
been spent as a teacher of Pediatrics. It is not presumption, 
therefore, to hope that the volume will be found not without 
merit, and that it will be acceptable and helpful to the medical 
student, and a welcome accession to the working library of the 
busy doctor. 

R. N. T. 

Chicago, November i, 1894. 



CONTENTS. 

PART I. 

CHAPTER I. 
Introductory i-iS 

CHAPTER IT. 
Therapeutic Hints 19^25 

CHAPTER III. 
Diseases and Accidents Immediately Following Birth . 26-31 

CHAPTER IV. 
Food and Feeding .......... 32-45 

CHAPTER V. 
Food and Feeding (continued) 4^-65 

CHAPTER VI. 
Nursery Hints 66-73 

PART II. 

Diseases of the Eye and Ear. 

chapter i. 

Diseases of the Eye 74-i^4 

CHAPTER 11. 
Diseases of the Ear 115-151 

PART III. 

Diseases of the Digestive Organs. 

chapter i. 

General Considerations 152-164. 

(vii) 



viii CONTENTS. 

CHAPTER II. PAGE 

ESOPHAGITIS 165-170 

CHAPTER III. 
Congenital Dyspepsia 171-17S 

CHAPTER IV. 
Diarrhea ........... 179-199 

CHAPTER V. 
Constipation 200-206 

CHAPTER VI. 
Intestinal Parasites 207-217 

CHAPTER VII. 

Intestinal Obstruction 218-221 

CHAPTER VIII. 
Dentition 222-232 



PART IV. 
DIATHETIC Diseases. 

CHAPTER I. 
General Considerations 233-234 

CHAPTER II. 
Rachitis 235-249 

CHAPTER III. 
Acute Tuberculosis — Tabes Mesenterica . . . 250-256 

CHAPTER IV. 
Scrofula ............ 257-266 

CHAPTER V. 
Infantile Syphilis 267-271 

PART V. 

The Eruptive Fevers. 

chapter i. 

General Considerations . 272-275 



CONTENTS. ix 



PAGE 



CHAPTER II. 

Measles 276-283 

CHAPTER III. 

ROTHELX ............ 2S4-288 

CHAPTER IV. 
Scarlet Fever — Regular, Irregular, Malignant . . 289-316 

CHAPTER V. 
Roseola 317-321 

CHAPTER VI. 
Varicella, Vaccinia, Vaccination, Virus, Revaccina- 

TioN 32^-335 



PART VI. 

Non-Eruptive Contagious Diseases. 

chapter i. 

Diphtheria — Laryngeal Diphtheria, Intubation and 

Tracheotomy ......... 336-370 

CHAPTER II. 
Whooping Cough — Pertussis 371-379 

CHAPTER III. 
Parotiditis — Mumps 380-3S2 



PART VII, 

Affections of the Heart, 
chapter i. 

Position, Anatomy and Fetal Circulation . , . 383-386 

CHAPTER II. 
Congenital Diseases of the Heart : 

Cyanosis, Valvular Diseases, Endocarditis, Pericarditis . 387-419 



PART VIII. 

Disorders of the Urinary Tract. 

chapter i. 

The Urine of Infancy and Childhood : 

Collecting, Examination, Specific Gravity, Sediment . 420-434 



X CONTENTS. 

CHAPTER II. PAOE 

The Urine in Various Disorders of Childhood . . 435-438 

CHAPTER III. 
Acute Nephritis, Subacute Nephritis 439-450 

CHAPTER IV. 
Pyuria and Hematuria ........ 451-455 

CHAPTER V. 
Cancer in the Urinary Tract : 

Cancer of Prostate, Tumors of the Bladder, Renal Cancer. 

Sarcoma of the Kidney, Hydronephrosis . . . 456-461 

CHAPTER VI. 
Calculus in the Urinary Passages 462-463 

CHAPTER VII. 

Uricemia . . 464-469 

CHAPTER VIII. 
Diabetes Mellitus ......... 470-4S8 

CHAPTER IX. 
Diabetes Insipidus ......... 489-493 

CHAPTER X. 
Enuresis 494-507 



PART IX. 

Diseases of the Respiratorv Organs, 
chapter i. 

General Considerations : 

Collapse of Lung, Dyspnea, Percussion, Cough . . 508-514 

CHAPTER II. 
Coryza 515-51S 

CHAPTER III. 
Epistaxis ........... 519-523 

CHAPTER IV. 

TONSILITIS 524-533 

CHAPTER V. 

Laryngitis, Spasmodic Laryngitis, Chronic Laryngitis, 

Laryngismus Stridulus 534-537 



CONTENTS. xi 

CHAPTER VI. PAGE 

Acute Membranous Laryngitis ...... 538-55^ 

CHAPTER Vn. 

Pneumonitis 552-5^4 

CHAPTER VHI. 
Bronchitis, Capillary Bronchitis 5^5-576 

CHAPTER IX. 
Asthma— Emphysema 577-5^2 

CHAPTER X. 
Atelectasis 5^3-5^7 

CHAPTER XI. 
Pulmonary Phthisis 588-594 

CHAPTER XII. 
Pleurisy 595-603 

PART X. 

General Diseases, 
chapter i. 

Cerebro-Spinal Fever 604-614 

CHAPTER 11. 
Infantile Typhoid Fever: 

Enteric Fever, Infantile Remittent Fever, Typho-Malarial 

Fever, Typhus Abdominalis, Continued Fever . . 615-627 

CHAPTER III. 
Intermittent Fever : 

Malarial Fever, Chills and Fever, Miasmatic Fever, 

Ague 628-637 

CHAPTER IV. 

Rheumatism 638-641 

CHAPTER V. 

Adenitis, Lymphadenitis : 

Non-Specific Inflammation of the Lymphatic Glands . 642-646 



xii CONTENTS. 

PART XI. 

Affections of the Nervous System. 

chapter i. page 

Introduction 647-651 

CHAPTER II. 
Convulsions in Children: 

Epilepsy 652-661 

CHAPTER III. 
Chorea : 

St. Vitus' Dance 662-671 

CHAPTER IV. 
Infantile Tetanus : 

Trismus Nascentium, Lockjaw ...... 672-674 

CHAPTER V. 
Paralysis : 

Cerebral Paralysis, Multiple Cerebro-Spinal Sclerosis, 
Cerebral Hemorrhage, Thrombus, Embolism, Cerebral 
Tumors, Spinal Paralysis, Potts' Disease, Myelitis, 
Acute Idiopathic Myelitis, Chronic Myelitis, Anterior 
Polyomyelitis, Spinal Hemorrhage, Primary Lateral 
Sclerosis, Pseudo-Hypertrophic Paralysis, Paralysis of 
the Portio Dura ......... 675-709 

CHAPTER VI. 
Hereditary Ataxy: 

Acquired Locomor Ataxy 710-71 2 

CHAPTER Vn. 

Idiocy 713-717 

CHAPTER VIII. 
Insanity : 

Hysteria 718-728 

CHAPTER IX. 
Disorders of Sleep: 

Night Terrors 729-732 

CHAPTER X. 

Headaches in Children 733-734 

CHAPTER XI. 
Congestion of the Brain 735-74^ 



CONTENTS. xiii 

CHAPTER XIL page 

ISIexixgitis, Simple Meningitis, Tubercular Meningitis 741-749 

CHAPTER Xni. 

Hydrocephalus » . 750-756 

PART XII. 

Diseases of the Skin, 
chapter i. 

Eczema, Crusta Lactea, Moist Tetter, Salt Rheum . 757-770 

CHAPTER II. 
Psoriasis, Psora, Dry or Scaly Tetter .... 771-774 

CHAPTER III. 
Miliaria Rubra, Red Gum, Strophulus, Tooth Rash . 775-776 

CHAPTER IV. 
Erythema, Rose Rash . . . . . . . . 777-780 

CHAPTER V. 
Zoster, Herpes Zoster, Zona, Shingles .... 781-7S3 

CHAPTER VI. 

Erysipelas, St. Anthony's Fire 784-789 

CHAPTER VII. 
Impetigo Contagiosa ......... 790-792 

CHAPTER VIII. 
Urticaria, Nettle Rash, Hives 793-797 

CHAPTER IX. 
Trichophytosis, Ring Worm 79S-801 

CHAPTER X. 
Scabies, Itch 802-805 



THE DISEASES OF CHILDREN. 



PA RT I . 



CHAPTER I. 

INTRODUCTORY. 

The period of " infancy," when used in a medical sense, is 
understood as covering the time from birth to the completion 
of first dentition, which occurs as a rule when the child is about 
two and a half years of age. 

Childhood covers the period from infancy to puberty, w^hich 
in this country is reached at an age of twelve to fourteen. 
When taken together they constitute an epoch in human life 
which is fraught with absorbing interest. Until within the last 
thirty years no American medical college had paid any special 
attention to the diseases peculiar to childhood ; no children's 
clinics were held, and all that the medical student could learn 
about them was to be found in the text-books and didactic 
lectures on general practice. Now, however, all of our princi- 
pal medical colleges have a special chair of pedology ; special 
children's clinics are deemed as necessary as any other, and 
numerous large and comprehensive treatises devoted to this 
subject are among the most highly prized volumes in every 
intelligent physician's medical library. 

It is not at all strange that this should be so. The period 
referred to is essentially different in every aspect from adult- 
life. The anatomy, the physiology, the pathology and the 
therapeutics of infancy are all sufficiently different to require 
special study and special knowledge for their proper under- 
standing. That adults occasionally and exceptionally have 
diseases that as a rule are found only among children, does not 
militate against this statement. 

One might practice medicine for a lifetime among adults 
without meeting a typical case of measles, or scarlet fever, or 
diphtheria, nor would he know anything about the aberrations 

(1) 



2 THE DISEASES OF CHILDREN. 

of development. Under such circumstances he surely could 
know nothing about the peculiarities of the infantile stomach, 
or the idiosyncrasies of the undeveloped nervous system. 
Even if he had practiced for years among the deaf and dumb 
he would be sorely puzzled to interpret aright, at the first en- 
counter, the disease language of infancy. 

And yet to one who has carefully studied the habits and char- 
acteristics of infants, the absence of articular speech is no bar- 
rier usually to a correct diagnosis ; and the careful observer can 
often tell at a glance by features, attitude or behavior all that 
language could convey of the seat and nature of the ailment. 
In some respects the diagnostician is aided by the dumbness 
of his patient. If there is no speech, so also there is no pre- 
varication nor dissimulation. The infant does not, intention- 
ally or otherwise, place undue stress on trifling symptoms 
which might conceal or obscure a real and serious malady. In 
pulmonary complaints the absence of visible sputa is not a 
serious loss, for other signs are present and available to make it 
easy to estimate the true condition of affairs. The same is 
true of the urine. Indeed, I fancy that with the exercise of 
a due amount of patience, the skillful physician will make 
fewer mistakes in diagnosing the ills of infancy than in an 
equal number of those maladies more commonly met with 
in adults, however intelligent and voluble they may be. To 
point out and elaborate in detail all of the differences be- 
tween child-life and adult-life would rehire a volume larger 
than this and would then be more curious and interesting 
than useful. 

There is scarcely an organ or a tissue that behaves precisely 
alike in the two epochs. In maturity there is, until old age 
begins, a daily balance between waste and repair. There is no 
increase in growth, or material change in organ or function. 
Childhood, however, is a period of rapid change — of growth 
and development. 

Some of the organs, such as the reproductive, whose offices 
are to cut an important figure later on, are now dormant and 
inactive. Others having done important work during embry- 
onic life are ceasing their activity and undergoing a more or 
less rapid process of absorption — atrophy. 

Anatomical Peculiarities of Infancy. — In a general 
way it may be said that at birth the bones are more elastic and 
less firm ; they contain more animal and less earthy matter 
than in advanced years ; they are more cartilaginous, and their 
growth is more from cartilage than periosteum. Certain aber- 
rations of ossification are now noticeable in certain cases which 



ANATOMICAL PECULIARITIES. 3 

may destroy the symmetry of normal growth or prejudice the 
life of the child. The skull, which is intended to support the 
brain and its blood vessels, may prevent their due develop- 
ment, while an insufficient degree of ossification or an undue 
amount of sutural substance may conduce to an enlargement 
of the blood vessels and consequent effusion. The separate 
b(/nes of the skull are but loosely articulated at first, but at a 
variable period the sutures are ultimately obliterated. The 
yielding nature of the skull at this time is such that it may be 
indented by a blow, or compressed by a bandage, or its shape 
may even be altered by the weight of the contained brain, if 
the infant is allowed to lie habitually on one side. 

The fontanels are two irregular but somewhat triangular 
openings with membranous coverings at the angles of the pari- 
etal bones. The ant?fii^ and larger one of the two fontanels 
is situate at the junction of the parietal and frontal bones, or 
more correctly speaking, at the junction of the coronal and 
sagital sutures ; the posterior, at the junction of the parietal 
and occipital bones. As a rule, these fontanels are larger at six 
months of age than they are at birth, the reason being that the 
growth and expansion of the brain within the calvaria goes on 
more rapidly than the process of ossification. The latter, how- 
ever, soon overtakes the former and both fontanels should be 
closed before the end of the second year. They are often 
closed much earlier than this — as soon, indeed, as the fifteenth 
or sixteenth month. When remaining unclosed into the third 
year, the fact has a significance that will appear when we come 
to speak of rickets. 

During infancy and childhood the jaw and the teeth are in 
a rudimentary state, and their lack of development makes the 
facial portion of the skull look disproportionately small. The 
upper and lower maxillary bones undergo various modifications 
until both the temporary, and permanent teeth are completed, 
and indeed do not reach their fixed and ultimate form until the 
age of puberty. The evolution of the teeth and the progress- 
ive stages leading thereto will be treated of later on under the 
head of teething. 

The vertebral column is straighter and the insertion of the 
ribs more rectangular at their insertion at the transverse pro- 
cesses of the vertebra and the sternum. This renders respira- 
tion more abdominal than costal and the viscera of the abdom- 
inal cavity appear more prominent. 

The nervous system in infancy probably shows greater differ- 
ences relatively than any other portion of the anatomy. The 
brain at birth is very large. Its weight is one-sixth of the 
entire weight of the body, while in the adult it is one-sixtieth. 



4 THE DISEASES OF CHILDREN. 

The brain substance is soft and pasty and less distinctly sepa- 
rated into medullary and cineritious matter ; indeed, its gray 
and white substances differ but little in color and composition. 
The convolutions are less prominent and less numerous. The 
nerves of special sense are fully developed, but are inactive. 
The nerves of organic life — the sympathetic — are quite pro- 
portionate to age and development. 

The spinal cord, like the brain, has not yet the consistency of 
a later period. The anterior hornS are unduly prominent and 
are therefore especially sensitive to pathological changes. 
The peripheral nerves are relatively large, but lack the excita- 
bility they have later. Toward the end of the first year, how- 
ever, this excitability grows rapidly ; much more so than that 
of the inhibitory nerves. During the first month of extra- 
uterine life, all muscular movements are not controlled by will- 
power at all, but are purely reflex. After this time, however, 
the brain develops very fast indeed, although the development 
is by no means uniform. Certain cerebral functions spring into 
existence one after another, coincident with other anatomical 
evolutions. 

The lymphatic system is remarkably well developed in 
infancy, comparatively speaking. So also is the glandular. 
The liver is one of the first formed organs in the embryo and 
at the fourth week of embryonic life it occupies nearly the whole 
abdominal cavity, and constitutes one-half the entire weight of 
the body. From this time, however, it diminishes in bulk 
until birth, when it occupies nearly the upper half of the abdo- 
men, and its proportional weight to that of the body is as one 
to eighteen. During infancy and early childhood its position 
is such that its lower margin can be felt about half an inch 
below the costal cartilages. In the middle line the liver is in 
close relation to the skin in front of the stomach and reaches 
about half way between the ensiform cartilage and the umbil- 
icus. Here its lower edge corresponds to a line drawn from 
the ninth right to the eighth left costal cartilage. 

The thymus gland is situated just behind the top of the 
sternum, extending when fully developed, at the end of the 
second year, into the root of the neck over the trachea and 
separated from the great vessels by the thoracic fascia. It 
rests below upon the pericardium, just above the point where 
the pleura approach each other. After the second year it 
diminishes until it entirely disappears or is substituted by a 
mass of fat. It is of a pinkish gray color and lobulated, and 
at birth weighs half an ounce. Its disappearance takes place 
often at the age of puberty and sometimes not until after mid- 
dle life is reached. — McLellan. 



PHTSIOLOGICAL PECULIARITIES. 5 

The stomach in infancy presents some peculiarities which 
are worthy of mention. The most noticeable of these is the 
vertical position which it occupies in the abdomen. In the new 
born it presents more the appearance of a simple enlargement 
or expansion of the esophagus. Its fundus is wanting and it 
does not have the larger and smaller curves. The valvular 
construction of the cardiac orifice is deficient in infants, which 
accounts for the facility with which they vomit when the vis- 
cus is from any cause over distended. 

The circulatory system of the newly born, except during the 
first few days, shows but little change from that of the adult, 
except that the veins are relatively small while the arteries are 
relatively large. Shortly before birth the heart loses those 
peculiarities which distinguish the fetal heart and the organ 
rapidly assumes its normal condition for life. The changes 
which take place in the circulation of the blood at this time 
are remarkable. The umbilical vein and the ductus venosus 
become empty and contract and are ultimately converted into 
the fibrous cords which become the round ligament of the 
liver. But, as Holden says, '' It is well to bear in mind that 
these important vascular changes do not take place suddenly 
at birth, but that they are the result of gradual develop- 
ment which is completed at or soon after birth, mainly by 
the act of inspiration, whereby the blood passes through 
the lungs, the placental circulation at the same time being 
interrupted." 

Physiological Peculiarities. — Comparing infancy with 
mature age, there is a similar difference to be noted in the phys- 
iology as well as in the anatomy of the organism. To be sure, 
all of the vegetative functions, those which are essential to life, 
are performed, but most of them are but feebly carried on and 
these are easily disturbed by trifling causes. The skin of the 
new born, when cleansed of its sebaceous matter and its vernix 
caseosa, is found to be much more red and sensitive than in later 
life, and during the first few weeks after birth there is usually 
more or less desquamation. There is but little perspiration, 
but the sebaceous glands are very active, especially on the scalp. 
Unless this sebaceous matter is constantly cleansed away, in- 
fantile eczema is very prone to result. During the first three 
or four months there is no secretion of tears. The new born 
and the dying do not weep. After the first three or four 
months, the absence of tears is not a good sign. It has been 
found that the blood of infants is less in proportion to weight 
of the entire body than in adult life ; and this blood has " less 
fibrin, fewer salts, less hemaglobulin, less soluble albumen, less 



6 THE DISEASES OF CHILDREN. 

specific gravity and more white corpuscles than the blood of 
advanced age." 

The pulse of infants and children is very irritable and easily 
influenced by slight, even physiological, causes. It is also very 
irregular in rhythm, owing to the variability and instability of 
the nerve supply. Indeed, the pulse in infancy is so easily per- 
turbed that it loses, when considered alone by itself, much of 
its usual pathological significance. 

The normal frequency of the pulse at birth is 140 and during 
the first few weeks of life may fluctuate between 150 and 120, 
being rather more frequent in females and in smaller infants. 
At the end of the first year the rate varies from 100 to 120. 
After this the pulse beats about 100 and gradually becomes 
less frequent until at five years the normal frequency is gener- 
ally about 90. 

The respiratory function is subject to the same variableness 
as the pulse. During the first few months it is no uncommon 
thing to find a veritable Cheyne-Stokes rhythm, which is either 
normal or occasioned by causes so trivial as scarcely to be con- 
sidered as pathological. At birth the number of respirations 
per minute varies from 30 to 50, the mean between these figures 
being the average. They are fewer during sleep and are then 
also more regular. During the first year of life the respirations 
range between 25 and 35, but these figures are increased by 
crying or laughing and diminished by fixing the infant's at- 
tention. Von Pettenkofer has estimated that a child produces 
in proportion to its body-weight nearly three times as much 
carbonic acid as an adult. 

Temperature. — The clinical thermometer is of the greatest 
value in the treament of the diseases of infancy and cannot 
safely be dispensed with. The feeling of the skin is very decep- 
tive. The hand may detect no fever at all when the internal tem- 
perature may be raised several degrees above the normal. It 
is one of the peculiarities of infancy that very slight and tran- 
sient causes produce a sudden elevation of the temperature, al- 
though, as a rule, in a healthy child the thermometer shows a 
fairly constant mean of 99° in the rectum. It rises a half-degree 
or so after a hearty meal, but there is no marked difference in 
health between the morning and evening. 

On account of the excitability of the nervous system which 
has already been referred to, children are very subject to what 
may be called '* irritative fever," i. e., a form of pyrexia which 
results from any trifling cause that frets or worries it. 

Dentition is a frequent promoter of this form of febrile ex- 
citement and so is irritation of the bowels by scybala, food 



GROWTH. 7 

injested that does not quite agree and intestinal worms. This 
irritative fever of which we are speaking is always marked with 
great irregularity. There is no regular evening exacerbation or 
morning remission as in most other forms of pyrexia. 

Sometimes, instead of an elevation, the thermometer shows a 
marked lowering of the temperature. This is usually a sign 
of malnutrition. Anything which exhausts the system, like 
chronic vomiting or purging, is likely to be followed by a fall in 
temperature. In convalescence -from acute diseases, the tem- 
perature may remain for days or even weeks at a lower level 
than that of health. Dr. Eustace Smith has observed that chil- 
dren who are growing rapidly are subject to a nightly rise in tem- 
perature, the thermometer sometimes ranging as high as ioo° or 
100.6°. Under these circumstances, this phenomenon is physio- 
logical and not pathological in its nature. In infants the tem- 
perature should always be taken in the rectum. Here the 
thermometer can always be used safely and an accurate registry 
secured. This cannot be said of the axilla or the groin. 

Growth. — The average weight of a healthy infant at birth 
is seven pounds, the female being somewhat less heavy. This 
weight is about doubled at five months, and trebled at the 
end of the first year of life. 

The average length of a child at birth is 19*5 inches, and the 
subjoined table of the monthly rate of increase is given by 
Louis Starr. 

Birth 195 inches 

1 month 20 ■ 5 " 

2 months 21 " 

3 months 22 " 

4 months 23 " 

5 months 23 ' 5 " 

6 months 24 " 

7 months 24*5 " 

8 months 25 " 

9 months 25*5 " 

10 months 26 " 

1 1 months 26 ' 5 " 

12 months 27 " 

" During the second year the increase is from three to five 
inches ; in the third from two to three and a half inches ; in 
the fourth from two to three inches." 

The gain in weight per annum for the first few years averages 
four or five pounds. 

For five years and onwards the figures both for height and 
weight have been worked out by Dr. G. W. Stephenson, whose 
table is subjoined. 



THE DISEASES OF CHILDREN. 



AVERAGES OF HEIGHT AND WEIGHT OF BOYS AND GIRLS OF ENGLISH 

SPEAKING RACES, CALCULATED FROM THE TOTAL OF 

BRITISH AND AMERICAN STATISTICS. 



BOYS. 



Girls. 







^ 


Age. 


Height in 
inches. 


Weight in 
pounds. 


5 


4' 30 


40 49 


6 


43-88 


44 79 


7 


45-86 


49 39 


8 


47 41 


54 41 


9 


49 69 


59 82 


ID 


51-76 


66 40 


II 


53 47 


71 09 


12 


55 05 


76 81 


13 


57 06 


83 72 


14 


59 60 


93 46 


15 


62 27 


104 90 


i6 


64 66 


120 00 


17 


66 20 


12919 


.8 


66 81 


134 97 







^ 


Age. 


Height in 
inches. 


Weight in 
pounds. 


5 


41 05 


39 63 


6 


42 99 


42-84 


7 


44 98 


47 08 


8 


47 09 


52-12 


9 


49 05 


56 -28 


10 


5119 


62-17 


II 


53 26 


68-47 


12 


55 77 


77 35 


13 


57 96 


87-82 


14 


59 87 


97 ■ 56 


15 


61 01 


1 05 44 


16 


61 67 


11236 


17 


62-22 


iit;'2i 


18 


62 19 


116-43 



Dr. H. Parker, Resident Physician of the New York Infant 
Asylum, weighed immediately after birth 170 infants — 89 males 
and 81 females — born consecutively and at term, with the 
following result : 

Average male weight 7 lbs. 11 02. 

Average female weight 7 lbs. 4 oz. 

Fifty of these who were wet-nursed and apparently well 
taken care of, were weighed when one week old, with the 
following result : 

Increase of weight in 32 cases 

Loss of weight in 13 cases 

Average gain 4y^^ oz. 

Average loss 3^^ oz. 

Greatest gain 12 oz. 

Greatest loss 6 oz. 

AVERAGE GAIN. 

From birth to age of four months (25 cases). .4 lbs. 8^ oz. 

From 3 to 6 months (6 cases) 3 lbs. 3^ oz. 

From 6 to 9 months (6 cases) 2 lbs. 7^ oz. 

From 9 to 1 2 months (6 cases) i lbs. 15)^ oz. 

This would indicate that American-born babies were some- 
what heavier than the average of English-speaking races, 
according to Stephenson's tables. 



PATHOLOGICAL PECULIARITIES. 9 

Pathological Peculiarities.— Most of the observations 
and deductions that would properly come under this head will 
be spoken of when the diseases are described which would illus- 
trate them. A few of these peculiarities, however, may be 
mentioned here, since they are of a general nature and are more 
incidental to the time of life than to any peculiarity of the dis- 
ease itself. The peculiarities referred to often invest the com- 
monest forms of illness with strange features which may be a 
source of obscurity and confusion. A functional derangement 
which in the adult would give rise only to slight local symptoms^ 
may in the child be accompanied by signs of some general dis- 
tress and the presence of local suffering may be thus over- 
shadowed or completely concealed. 

The swallowing of a small portion of indigestible food may 
throw the child into a burning fever, with intense agitation and 
restlessness, or it may cause convulsions or stupor from which 
it can with difficulty be aroused. I once knew a child of my 
friend Dr. S. P. Hedges, of this city — a child some two years 
old — to have convulsions at frequent intervals all one day from 
eating some partially cooked mashed potatoes. As soon as the 
offending substance was expelled from the system the convul- 
sions ceased and the child resumed its play as well as ever. 
Indeed, it may be stated that an eclamptic attack in a child is 
a symptom which, in the majority of cases, has far less signifi- 
cance than a similar attack would have in an adult. In the 
latter it is usually the evidence of some serious cerebral lesion 
and its occurrence excites quite naturally the greatest alarm. 
In the child, however, a ''fit" is commonly the evidence only 
of some disturbance in the nervous system, the amount of act- 
ual disturbance and the symptoms being very disproportionate. 
It may be only a trifling irritant of the most transient nature, 
and of no gravity whatever. In the beginning of acute illnesses, 
such as the eruptive fevers, we often have spasms at the outset, 
taking the place of the rigor so common a symptom in the begin- 
ning of febrile disease in the adult. It is not to be understood, 
however, that convulsions in the child are always of this inno- 
cent character. They may and do occur as a consequence of 
cerebral disease, but in such cases are frequently repeated or 
are prolonged and are succeeded by coma, rigidity, paralysis or 
other signs of centric irritation. Vomiting, which in the adult is 
often indicative of grave gastric or other organic disease, is in 
children a symptom of the most trifling import usually, and 
means or may mean only an overloaded stomach. ''As pro- 
found a disturbance may be excited by the simplest functional 
derangement as by the severest organic malady, so that, to the 
eye accustomed to the orderly progress of disease in the adult. 



10 THE DISEASES OF CHILDREN. 

symptoms seem to have lost their value and to be calculated 
rather to mislead than to inform." 

Children sometimes suffer the most violent nocturnal delir- 
ium — the so-called " night terrors" — from slight derangement 
of the stomach from worms or otherwise. 

Another peculiarity of infants is the fact that they quickly 
part with their heat and are easily chilled. They are therefore 
especially prone to catarrhal affections, which may seriously 
interfere with the functions of the organ involved, and this ar- 
rest of function may of itself lead to fatal results ; and a child 
may die with tissues sound, organs healthy and no morbid ap- 
pearances left to declare the nature of the complaint. Post- 
mortem examinations have been made of children dead from 
marasmus, in whom not the slightest trace of organic disease 
has been discoverable. 

The gravity of certain, indeed it may be said of all, diseases 
is modified either one way or another by age. Typhoid fever, 
measles, and perhaps croupous pneumonia generally run a 
milder course in earlier than they do in later life ; but others, 
such as acute affections of the gastro-intestinal tract, are far the 
more severe in comparison with the youth of the patient. The 
infant is so dependent upon a frequent supply of nourishment, 
that any abrupt interference with the nutritive processes is an 
event of the utmost gravity. It is often followed by so much 
exhaustion that the infant rapidly sinks and dies. It is this 
sudden and complete cutting off of the nutritive supply which 
constitutes the chief danger of acute disease, and all through 
early life illness is often serious in exact proportion to the 
degree in which the alimentary canal participates in the de- 
rangement. When children retain their ability to eat and 
digest, while passing through an acute illness, their recovery is 
generally assured and their convalescence rapid. In uncom- 
plicated cases the strength appears to be recovered almost as 
quickly as it was lost. When, in such cases, convalescence is 
delayed it is almost invariably due to a complication, a 
thing which is far from being uncommon. 

From chronic maladies convalescence is usually slow, the 
delay being no doubt partly due to the fact that this class of 
diseases is more common in children of a scrofulous habit and 
the strumous cachexia, as is well known, is in itself a barrier to 
rapid improvement. Another reason for this tardiness in re- 
covery is found in the fact that in children chronic ailments 
nearly always, in the course of their progress, sooner or later 
affect the alimentary canal and such complaints are invaria- 
bly slow. 

When sudden death occurs to a child previously healthy, or 



S/GA^S OF DISEASE, 11 

at least to all appearances so, it is usually due to laryngismus, 
to syncope, or to collapse of the lung. Occasionally, although 
not frequently, it is a consequence of convulsions. Pulmonary 
collapse is frequently met with in infants or children who have 
been greatly enfeebled by some wasting disease. A fatal ter- 
mination of disease is usually marked by a sudden alteration of 
the temperature, either dropping below the normal or rising 
quickly to io8° or 109°. The former is more apt to be the 
case in chronic diseases or in collapse of the lung, the latter in 
cerebral cases or gastro-intestinal derangements. 

Signs of Disease. — " The clear, fresh complexion of a 
healthy baby or a young child is familiar to everyone. X loss 
of its purity and clearness is one of the first indications of 
digestive derangement. The face becomes muddy-looking 
and the upper lip whitish or bluish. Blueness of the upper lip 
in early life is a common sign of labored digestion. In some 
children dif^cult digestion is shown by an earthy tint of the 
face Avhich spreads to the forehead. It appears a short time 
after the meal and may last several hours. In chronic bowel 
complaints the earthy tint is constant. It is common in cases 
of chronic diarrhea in the infant, and if at the same time there 
is much emaciation, the derangement is likely to prove 
obstinate. In syphilis the prominent parts of the face — the 
nose, cheeks, chin and forehead — assume a swarthy hue. In 
lardaceous disease the complexion is peculiarly pallid and 
bloodless ; in rickety children whose spleens are greatly en- 
larged it has a greenish or faint olive cast ; and in cyanosis the 
face has a characteristic leaden tint, the conjunctiva are con- 
gested, and the eyelids and lips thick and purple. Lividity of 
the skin around the mouth and nose with a purple tint of the 
eyelids is common as a result of deficient aeration of the blood. 
In severe cases the cheeks at the same time have a dull white 
color, and the symptom is an unfavorable one. In the spas- 
modic stage of whooping-cough the face looks swollen as well 
as livid, the lips and eyelids are purple and thick, and the con- 
junctiva are congested and often bloodshot. 

" In addition to the actual tint of the face, the general expres- 
sion must receive attention. In a healthy babe the physiog- 
nomy denotes merely sleepy content, and no lines mark the 
smooth, uniform surface. Pain is indicated by a contraction of 
the brows which wrinkles the skin of the forehead. This is 
especially noticeable if the head is the seat of suffering. If 
the pain be in the abdomen, the nose often looks sharp, the 
nostrils are dilated, and the child draws up the corners of the 
mouth with a peculiar expression of distress. In every case of 



12 THE DISEASES OF CHILDREN. 

serious disease the face, even in repose, has a haggard look, 
which must not be disregarded. If this be accompanied by a 
hollowness of the cheeks and eyes the result is a ghastly ex- 
pression which cannot escape attention ; but a distressed look 
may be seen in the face, although there is no loss of roundness 
of feature. If this be the case, even in the absence of striking 
symptoms, we may confidently predict the onset of serious 
disease. 

*' Often an inspection of the face will help us to a knowledge 
of the part of the body affected. Many years ago M. Jadelot 
pointed out certain lines or furrows in the face of an ailing- 
infant which by their position indicate the seat of the derange- 
ment, thus: 

"• The occulo-zygomatic line begins at the inner canthus of the 
eye, passes thence downwards and outwards beneath the lower 
lid and is lost on the cheek a little below the projection of the 
malar bone. This line points to disease or derangement of the 
brain and nervous system. 

"The nasal line rises at the upper part of the ala of the nose 
and passes downwards, curling round the corner of the mouth. 
This line is a constant feature of abdominal mischief, and is 
never absent in cases of gastro-intestinal derangement. 

** The labial line begins at the angle of the mouth and runs 
outward to be lost in the lower part of the face. This is more 
shallow than the preceding. It is a fairly trustworthy sign of 
disease in the lungs and air-passages. 

" These lines have a distinct practical value and should be 
always attended to." — Eustace Smith. 

The attitude of the child as he lies in his cot is not to be 
overlooked. It is sometimes very significant. Healthy infants 
and children sleep perfectly quietly. Frequent turning of the 
body, twitching of the muscles, jumping and starting, always 
indicate some derangement somewhere. It may indicate 
merely feverishness or digestive derangement, but it is a depar- 
ture from perfect health. If the head is moved constantly 
from side to side on the pillow it is probably annoyed with 
pain in the head or ear. When the hand is frequently car- 
ried to the forehead or side of the head it usually means the 
same thing. 

Some writers attach much importance to the cry of the child 
and seem to regard its character as having much significance. 
There is to their minds a hungry and a thirsty cry, a cry indica- 
tive of colic and another peculiar to earache. I must confess 
that I find in these cases that the cry is generally supplemented 
by other movements of the body, that to me are more signifi- 
cant than the cry itself. But these movements must be studied 



EXAMINATION OF SICK CHILDREN. 13 

at the bedside and each for himself. They are indescribable by 
words. The absence of crying is a serious omen. 

All healthy children cry whenever anything causes pain or 
discomfort. When it does not do so, it betokens or may be- 
token serious disease. There is one cry, however, that is so pe- 
culiar and so significant that it deserves special mention. It is 
the " cri excephalique " of the French. It is sharp, shrill and 
solitary and is distinctive of cerebral disease. 

It is very different, the very antipodes of the long-drawn 
moans and wails of marasmus and tubercular peritonitis. 

Examination of Sick Children. — Nearly every work upon 
diseases of children contains several pages of more or less ex- 
plicit directions as tohow the student or the young practitioner 
is to go to work to examine a child who is supposed to be ill, in 
order that he may ascertain the seat and nature of the com- 
plaint and be able to prescribe intelligently therefor. 

1 see but little reason for this. The printed page can never 
teach the novice to be an expert. The medical practitioner 
who essays to treat successfully the diseases of infancy must 
have great patience and greater tact. Both of these accom- 
plishments may be cultivated, but they cannot be taught. 
Their possession is a gift rather than an acquirement, and all 
the written directions in the world cannot teach that which is 
inherently wanting. To illustrate, I find this in a volume be- 
fore me : " To examine the abdominal organs at all satisfactor- 
ily, the child must lie on his back with his head and shoulders 
raised by a pillow. The mother or nurse should sit upon the 
bed by his side and the practitioner should take care that the 
hand he applies to the belly is warm and does not press too 
abruptly, so as to give pain. This part of the examination is 
usually submitted to without opposition if the child be hu- 
mored and cheerfully talked to, etc." 

This is all well and good, but why waste words and time try- 
ing to teach a man to warm his hands before putting them on 
the abdomen of a sick child, or try to teach him to talk good 
humoredly or cheerfully to a child that is howling with pain ? 

This cannot be taught by books. To attempt to do so is to 
dally with failure. The place to learn how to handle a sick 
child is in the medical clinic or in the nursery, where practical 
experience is to be had. Practice is better than precept. What 
the doctor needs in the chamber of a sick babe is the same kind 
of common sense that he needs and must have to be a welcome 
visitor in any sick room, be it that of man, woman or child. 
Hard, practical, common sense mingled with plenty of sympa- 
thy and good nature are the essential requisites of success. 



14 THE DISEASES OF CHILDREN. 

No rigid rules can be laid down for the guidance of the exam- 
iner in a given case. The history of the ailment and the general 
history of the child should be obtained when possible from the 
mother or the nurse in charge. 

This history is oftentimes of the greatest importance. It 
sheds light or may help to decide the question of latent ten- 
dencies, or hereditary taint. It should serve to answer the 
question as to how the child has behaved in previous illnesses ; 
of their nature and duration. Mothers, as a rule, are careful 
observers, and their testimony should never be ignored. In 
trifling ailments it is usually not necessary to unclothe the child, 
nor subject it to prolonged and wearisome examination. But 
except in acute illnesses where the symptoms manifestly do not 
call for it, this is necessary. In all chronic complaints the child 
should be stripped to the skin, so that a thorough inspection 
can be made of the entire body. If the child is asleep at the 
time of the visit, so much the better. Certain points can be 
covered in the examination better than afterwards. For in- 
stance, the attitude ; the posture, if easy and natural, or other- 
wise; the color of the face, if flushed or pale; the color of the 
lips, if white or livid ; the state of the skin, whether moist or 
dry ; the expression, if natural or painful. We should note the 
presence or absence of moaning, starting, twitching, grinding of 
the teeth ; the action of the nostrils, if quiet or working 
strongly ; the eyes, if closed, or only partly closed, or staring; 
the respiration, whether abdominal or thoracic. The respira- 
tions may now be counted, as w^ell as the pulse. The condition 
of the fontanels should be noted ; if closed or open, if pulsat- 
ing, expanded or depressed. What is the relative size and 
shape of the head? Are the veins full and prominent? How 
long has the child been sleeping? A healthy child, under three 
months of age, should sleep twenty hours out of the twenty- 
four. During the next six months it should average from fif- 
teen to eighteen hours. All of these matters can be looked aft- 
er before the sleeping child is aroused, when the examination 
must proceed in a very different manner, and when, in many 
cases, all the tact and skill and patience and persistence of a 
major-general of infantry will necessarily be called into play. 
It is now that didactic teaching is worthless. When ill, the 
best-natured of babies is restless, fretful, irritable, and willful. 
It will not bear coercion. It resents a strange presence. It 
cannot understand the reason of being thumped and poked 
and handled in strange ways. Observations must be made be- 
tween cries ; and a glance must suffice for prolonged inspection. 
In many, indeed, perhaps in most cases, a little adroit cajolery 
will place the doctor upon such a footing of familiarity, that 



A US C UL TA TlOy. 1 5 

all needed information can be in time secured. But only by- 
patient and practiced effort. The special significance of the 
points above referred to, and which are to be elicited in the ex- 
amination, will be fully brought out as the book progresses. 
To speak of them now would only amount to iteration. Their 
meaning will be be best understood as symptoms of the mala- 
dies to which they are the usual accompaniments. 

Dr. Louis Starr, in his admirable work on the " Diseases of 
the Digestive Organs in Children," has given such succinct di- 
rections for examining the chest, that we quote the following 
paragraphs: 

Auscultation. — "With infants, the back of the chest is most 
conveniently auscultated when the child is held in the nurse's 
left arm, with his breast against hers, his chin resting upon her 
left shoulder, his left arm around her neck, and his head kept 
in position by her disengaged hand. The front, when reclining 
on the back on a pillovv-. The sides, when sitting upright on 
the lap, first one arm and then the other arm being lifted up to 
allow the observer's ear to be applied. Older children may be 
made to take the same positions as adults. 

" It is not sufficient to auscult the posterior aspect of the 
thorax alone, as is stated by some authors. The whole chest 
should be examined, particularly in doubtful cases. The signs 
of croupous pneumonia are most frequently discoverable at one 
or other base posteriorly ; the friction sound of pleuritis at the 
junction of the middle and lower third, laterally ; and the signs 
of emphysema at the apices anteriorly. Therefore, unless the 
exploration be thorough, important lesions may be overlooked. 

" In healthy infants the inspiratory act in ordinary breathing 
is superficial, and the respiratory murmur, as a consequence, 
feeble. If, however, a deep inspiration be taken, a frequent 
occurrence under excitemient and during crying, the murmur 
becomes loud, or assumes the character that Laennec termed 
puerile breathing. After the age of two years this form of res- 
piration is habitual. 

" Puerile breathing is characterized by its intensity, a prop- 
erty depending upon the thinness and elasticity of the chest- 
walls in childhood. There is no alteration in rhythm, the inspir- 
atory element of the murmur being directly followed by the 
expiratory, and this in turn by an interval of silence ; neither is 
there any change in the pitch or duration of the expiratory 
sound, which remains lower and shorter than that of inspira- 
tion. In other words, puerile respiration is simply a very in- 
tense vesicular respiration. The normal respiratory murmur 
is then feebler in infants, and louder in children over two years 
old, than in adults. 



16 THE DISEASES OF CHILDREN. 

" The breathing is louder over the anterior, lateral and poste- 
rior inferior regions of the thorax. Faintest over the scapular 
and the precordial area. This absence occurs most frequently 
in young children, and is most noticeable over the lower pos- 
terior portions of the lungs. In the interscapular region, the 
ear, being directly over the larger bronchi, readily detects a de- 
viation from the vesicular quality. Here the inspiratory mur- 
mur is loud, harsh and somewhat tubular in character. There 
is a slight pause between it and the expiratory murmur, and 
the latter is longer in duration and higher in pitch. There is, 
in fact, an approach to the bronchial type of breathing, which 
may always be heard in its purity by listening over the trachea. 

" Sometimes a difference in the breathing can be detected 
over the apices anteriorly. On the left side the vesicular quality 
is purer, on the right the intensity is greater. The difference 
is most decided in the expiratory element, which, also, may be 
slightly prolonged on the right w^hen compared with the left 
side. These modifications are due principally to the larger size 
and more horizontal course of the right primary bronchus. 
They are perfectly compatible with a normal state of the lungs. 
Should, however, the condition at the apices be reversed, and 
the intensity and prolongation of the expiratory sound be 
greater on the left side, the commencement of phthisis is indi- 
cated. 

" If the child speaks, cries or coughs while the ear is applied 
to the chest a muffled, rumbling sound, the normal vocal reso- 
nance, will be heard. At the same time, vibration of the walls, 
the vocal fremitus, can be felt. 

"The cardiac sounds are readily heard when the ear is placed 
on the precordia. In young infants the examination is some- 
what difficult, on account of the rapid and excitable action of 
the heart, but after the first year, the circulation becoming 
slower and more regular, there is little trouble in distinguish- 
ing the sounds, and even slight alterations produced in them by 
disease. The first sound is longer and graver than the second, 
and the rhythm is ordinarily quite regular. In health the sounds 
may be heard under both clavicles for a short distance to the 
right of the sternum, and sometimes over the whole anterior 
surface of the chest. After muscular effort or during agitation, 
the heart sounds may be audible over the posterior aspect of 
the chest, but they are more distinct in this position when the 
lower lobe of either lung is consolidated by pneumonic exuda- 
tion. The latter point is often of great value in distinguishing 
doubtful cases of pneumonia from pleural effusion. 

Palpation. — '' In practicing palpation the palmer surface of 
the well-warmed hand must be applied to the naked chest. 



PERCUSSION. 17 

This method of exploration is useful as a means of determining 
the number of respiratory movements, the degree of expansion 
of the thoracic walls, the position of the cardiac apex beat, the 
presence or absence of painful regions and of pleural or bron- 
chial fremitus, the existence of fluctuation in the intercostal 
spaces and the character of the- vocal fremitus. For the last 
purpose, though, it is hardly worth while to make a separate 
step in the examination, for the vocal vibrations can be readily 
distinguished by the ear when applied to the chest in auscul- 
tation. 

Percussion. — " In percussing the different surfaces of the 
chest, the child must be placed in the same position as for aus- 
cultation. When contrasting the two sides, percussion should 
be made in the identical regions, and during the same period 
of the respiratory movement. Babies, when constrained or when 
disturbed, hold their breaths in the intervals of crying, and as 
they always do so at the end of an inspiration, this is a favor- 
able time to seize for the comparative examination. The per- 
cussion strokes must be lighter than in the adult, but in other 
respects the operation in no wise differs. 

" In health the resonance will be found to correspond closely 
with the respiratory murmur. Thus, in infants under one year, 
the respiratory murmur being feeble, percussion is rather in- 
sonorous. Even at this age the case is different, when a deep 
breath is taken, and so soon as puerile respiration becomes es- 
tablished the resonance is uniformly intense. With the excep- 
tion of this greater intensity, the sound is exactly similar to 
that obtainable in adults. It is always attended, too, by a 
sensation of elasticity, appreciated by the finger used as the 
pleximeter. 

" Different portions of the thorax possess, normally, different 
degrees of sonorousness. 

" In front, the right side is markedly resonant from the clavicle 
down to the fifth interspace, or the upper border of the sixth 
rib in the mammary line, where the liver dullness begins. On 
the left side the resonance is equally intense, but it is en- 
croached upon by the gastric tympany, which extends upward 
as high as the seventh or sixth rib, as well as by the area of 
cardiac dullness. The latter forms an irregular triangle, of 
which one side is represented by a vertical line passing down 
the middle of the sternum, from the level of the fourth to the 
sixth rib ; the other, by an oblique line touching the upper ex- 
tremity of the first, and extending outward to the left, and down- 
ward, to terminate at the point of the apex beat ; and the base, 
by a line drawn from the central point of the lower edge of 
the sternum (the inferior extremity of the first line), along the 
D. C— 2 



1.8 THE DISEASES OF CHILDREN. 

sixth costal cartilage to the apex of the heart. Diminished 
resonance and elasticity are at once noticeable when the per- 
cussion passes from the lung to this area, though the precor- 
dial dullness is never so decidedly marked in children as it is in 
adults. 

'' Laterally, both supra-axillary regions are very resonant. 
The upper portions of the infra-axillary regions are a degree 
less resonant, and the lower portions are dull on account of 
the presence of the liver on the right and the spleen on the 
left side. The superior border of the liver dullness is found in 
the seventh interspace or at the eighth rib ; that of the spleen, 
at the upper edge of the ninth rib. Gastric tympany may sup- 
plant the pulmonary resonance over the left infra-axillary 
region. 

" Posteriorly, there is little resonance in the scapular region, 
particularly the supra-spinous portions. Over the inter-scapu- 
lar space the sound improves, but it is less resonant than anter- 
iorly or laterally. Over the infra-scapular regions the reso- 
nance is but little less pure than in front, until the tenth rib is 
reached on the right side and the liver dullness is again met 
with. On the left side the reasonance extends to the very 
base, the posterior splenic dullness being detected with diffi- 
culty. The right base is, therefore, naturally less resonant than 
the left, and this difference is especially marked during expira- 
tion, the liver rising higher at that time. 

" Affections of the lungs produce various alterations in the 
percussion sound. The chief of these are the substitution of 
tympany, of dullness and of flatness for the normal resonance, 
and of increased resistance to the finger for elasticity. Cardiac 
diseases cause changes in both the extent and the shape of the 
area of precordial dullness." 



CHAPTER II. 

THERAPEUTIC HINTS. 

The opinion is very widespread that because no fatal cases 
of narcosis have been recorded from the use of homeopathic 
drugs that the remedies we employ in our practice are entirely 
harmless in any dose and frequency of repetition. Our fellow 
practitioners of the older school, have always asserted that our 
attenuated medicines could be taken by the pound or bucket-full 
without fear of harm, so long as the quantity did not overtax 
the distensive capacity of the patient's stomach. As this work 
is not written with a missionary purpose, but rather to instruct 
those who have already become convinced of the efficacy and 
superiority of our therapeutic methods and measures, no argu- 
ment is here necessar\^ to refute so erroneous an idea. 

Nothing is useful that cannot be abused, and while homeo- 
pathic medicines in intelligent and skillful hands are only potent 
for good, there are some drugs in common use by practitioners 
of homeopathy that should be given to children with great 
caution, and with more circumspection than would be deemed 
necessary in administering them to adults. It may be remarked 
in this connection that a marked change has taken place in the 
practice of homeopathic physicians everywhere, within the last 
thirty years — a change which is noticeable, more especially in 
an increase of dosage and a growing skepticism regarding the 
intensification of drug action from dynamization — so called. 

A considerable number of new remedies of priceless value, 
but which the founder of our system never heard or dreamed 
of, have been, and are being, added to our pharmacopeia. Many 
of these new remedies, if not all of them, have been quite gen- 
erally adopted without subjecting them to the exhaustive 
*' provings " that obtained in the Materia Medica Pura of Hahn- 
neman. Such practice, it is freely admitted, is more or less 
empirical, but clinical experience indorses it, and only the nar- 
row-minded reject it. The author believes that he voices the 
sentiment of the representative members of our school of prac- 
tice, in saying, that at the present time we do not regard the 
therapeutic law of similars as all-pervading — applicable to all 
cases of sickness without exception or reference to causation; 
nor do we consider a drug more potent for good, the further it 

(19) 



20 THE DISEASES OF CHILDREN. 

is removed from the form in which it is found in nature. We 
believe, with Dr. J. P. Dake, that "the law of similars is not 
applicable to any diseases which are characterized by destruc- 
tion of tissues, or where the cause cannot be removed, or to 
such as are due to chemical action, mechanical violence, or 
unhygienic surroundings." 

Modern pathology has shed much light upon the nature and 
causes of many diseases, and shows that some are self-limited, 
and tend to recovery if left to the unaided power of nature ; 
while others are incurable from the beginning and can only be 
palliated, whatever the system or method of treatment. 

The intelligent physician cannot allow a dogma to close his 
eyes to these advances in medical science, nor can he afford, 
from mere devotion to such dogma, to allow a patient to suffer 
from pain which can be alleviated, but cannot be cured. The 
author is well aware of the fact that there are some able and 
intelligent practitioners of homeopathy who look askance at 
these modern tendencies and innovations, and are filled with 
apprehensions as to the result. The number of such persons, 
however, is small. No one need fear the light. True science 
cannot retrograde. Homeopathy is progressing upward and 
onward, not downward or backward. In the following pages 
remedies will sometimes be recommended which cannot be re- 
garded as strictly in accordance with the application of the law 
of similars, but which are sanctioned by experience, which is 
sometimes paramount to law, as we in our half-blindness are able 
to see and construe it. But it is not the province of this work to 
engage in polemics, nor to discuss questions which have no prac- 
tical import, such as the size of the dose, the degree of attenu- 
ation, nor the alternation, combination or repetition of reme- 
dies. The author prefers to leave these matters to the fancy 
or the experience or the teaching of the individual. It is 
within his province, however, to point out the fact that there 
are certain drugs which the combined experience of the profes- 
sion everywhere, regardless of schools, has come to regard as 
dangerous when given to the young. Over forty years ago, Dr. 
John B. Beck, published a volume of " Essays on Infant Thera- 
peutics," etc., in which he devotes several chapters to the dan- 
ger of giving opium, emetics and mercury to young subjects. 
In speaking of the effects of opium on children, he cites 
numerous cases where a single drop of laudanum has proven 
fatal to a young infant. The writer himself knows of several 
instances of death resulting from what was regarded as a per- 
fectly safe dose of paregoric, when given to very young 
children. The author's coachman lost a babe a week old from 
giving, on his own responsibility, a dose of a much advertised 



THERAPEUTIC HINTS. 21 

patent laxative medicine. Although given according to the 
printed directions, it proved fatal in less than an hour. A 
chemical analysis proved that it contained opium, although in 
its advertisements this fact was ostentatiously disclaimed. If 
the number of deaths of infants and children from anodynes, 
soothing syrups and the like, were known, the statement of 
actual facts would be something appalling. We have seen it 
stated that infants have been ptyalized by mercury when 
treated by followers of the homeopathic school. If this be 
true, it could only be by the grossest carelessness or the most 
inexcusable ignorance. It may be well, however, to state that 
mercury, even in our usual doses, should be given with care 
and not be continued for too long a period. Tartar emetic is 
another remedy of the greatest value, but which should be 
given with great care to young children. The writer once saw 
a child affected with uncontrollable emesis from this drug 
given in the third decimal trituration. Since that time he 
has never given it except after it has been greatly diluted with 
water. A two-grain powder 3'^ trit. should be dissolved in 
half a glass of water and given in teaspoonful doses as often as 
required. 

The pvropriety of giving alcoholic stimulants to children is a 
mooted one. In diphtheria of a malignant type we have seen 
good results from the exhibition of dilute alcohol used as a 
gargle, and of whisky taken internally ; and even in cases of 
very young children affected with diphtheria, we have given it 
almost to the point of intoxication. In some of the rapidly 
wasting diseases, or when there is danger of sudden collapse, 
alcoholic stimulants are appropriate and useful. But the habit 
of giving whisky and brandy to children whenever they com- 
plain of stomach ache, and the indiscriminate use which is made 
of them in domestic practice cannot be too severely condemned. 
It is a serious question whether alcohol in medicine has not 
done much more harm than good. 

Atropine is another drug, whose action should always be 
watched when administered to infants. Even when given in 
very minute doses it is liable to produce aggravations, and in 
susceptible subjects it will sometimes produce a quasi-erythema 
confusing to the neophyte. What has just been said of atro- 
phine holds true of all the so-called alkaloids. They should 
invariably be given in dilution, that is to say, dissolved in water, 
rather than in powder form. 

The use of so-called " tonics " is one that is greatly abused. 
The best tonics in the world are those which are most easily 
secured, and which are not sold at either the drug stores or the 
pharmacies, viz.: fresh air and good food. Quinine and iron in 



22 THE DISEASES OF CHILDREN. 

crude doses are very hard of digestion by the average infantile 
stomach, and when they are indicated our second or third deci- 
mal trituration is quite strong enough for all practical purposes. 
There is one "tonic" which is an exception to what has just 
been said. Cod-liver oil should not be classed among medi- 
cines, for it is really a food. It is a tonic, because all digestible 
foods are tonics. When the alimentary canal is in a state to 
absorb it, cod-liver oil is oftentimes of immense usefulness. It 
should be remembered, however, that the power of digesting 
fats in early life is not great and for this reason it should be 
given tentatively and in small doses. Two or three drops is 
enough for an infant under six months of age. 

In cases where the oil is not assimilated and yet seems to be 
indicated, its benefit may be secured by inunction. The skin 
absorbs it with great readiness. 

Whatever may be said for or against the use of tonics and 
stimulants, there can be no two opinions about giving to chil- 
dren the new coal-oil products known as anti-febrine, anti-py- 
rine, phenacetine, sulphonal, et id oinnc genus. Their action on 
the adult heart is not without danger, and they are altogether 
too powerful and too uncertain in their action to give to chil- 
dren under any circumstances or in any dose. 

It seems to have been forgotten of late years by very many 
physicians that the most efficient anti-pyretic in the world is 
water. By the proper application of plain, simple water in dif- 
ferent temperatures truly wonderful effects can be produced. 
Dr. Eustace Smith, in his excellent work on " Disease in Chil- 
dren " (1884) gives some admirable directions for giving baths 
with a view to getting their best therapeutic effects, and we 
quote the following paragraphs : 

"The question of reducing temperature, when this rises to 
a dangerous height, is an important one. Children often 
bear a high temperature well, and it is not always easy to 
say what degree of heat constitutes hyperpyrexia in a child. 
When the fever is due to a septic cause it is perhaps less 
well borne than when it is the consequence merely of a local 
inflammation. 

" In any case, if the temperature rise above 106°, or if the 
patient seem to be distressed by a less degree of heat, it is ad- 
visable to sponge the surface of the body with tepid water. 
If the fever be not reduced by this means, the child should be 
placed in a bath of the temperature of 75°, and be kept there 
until the pyrexia undergoes a sensible diminution. Usually 
sponging the surface will reduce the bodily heat by several de- 
grees, to the immediate relief of the patient. In cases of in- 
flammatory diarrhoea, even in babies of a few months old, the 



THERAPEUTIC HINTS. 23 

temperature often rises to 109° or 110°, and the child passes 
into a state of profound depression. When this happens, death 
is inevitable unless the pyrexia can be quickly reduced ; and 
tepid bathing is often successful in greatly retarding, if it do 
not actually prevent, a fatal issue to the illness. 

" In the treatment of disease in early life the remedies at our 
command are the same as are useful for similar conditions in 
the adult. On account, however, of the impressible nervous 
system in the young subject external applications are of greater 
importance in childhood than they become in after years. 
Amongst the remedies of the greatest value baths form a class 
of no little importance. According to the temperature of the 
water employed the bath becomes a sedative, a stimulant, or a 
tonic, as may be required ; and in these different shapes is often 
resorted to with great advantage. The usefulness of tepid 
bathing in reducing fever has already been referred to. 

" The warm bath (80° to 85° Fahr.) is very useful in cases of 
convulsions or great irritability of the nervous system, shown 
by agitation, restlessness, spasm or disturbed sleep. It calms 
the excitement, allays spasm, promotes the action of the skin 
and induces sleep. On account of its diaphoretic effect warm 
bathing is of great service in cases of Bright's disease. In in- 
fants the warm bath has a sensible influence in promoting the 
action of the bowels, and in cases of constipation is often a valu- 
able addition to purgative medicines. The child should remain 
from ten to twenty minutes in the warm water. 

" The Jiot bath (95° to 100° Fahr.) is of great value as a stimu- 
lant where there is sudden and severe prostration, such as occurs 
in cases of profuse diarrhoea, urgent vomiting, shock, or other 
cause which induces a temporary depression of the vital ener- 
gies. When employed in this way as a stimulant the child must 
not remain too long in the water or the stimulative effect will 
pass off and be succeeded by depression. For an infant three, 
and for an older child five minutes, will be sufficient immersion. 
The patient can then be removed, wiped rapidly dry, and laid 
between blankets with a hot bottle to his feet. This bath may 
be made more stimulating by the addition of mustard. Flour 
of mustard, in the proportion of one ounce to each gallon of 
water, is mixed up with a little warm water into a thin paste 
and placed in a piece of muslin. This is squeezed in the hot 
water until the latter becomes strongly sinapised. So pre- 
pared, the mustard bath is an important remedy in cases of 
prostration and collapse. The child should be held in the 
bath until the arms of the attendant supporting him begin 
to tingle. 

" The cold douche is a tonic of the utmost value. It must, 



24 THE DISEASES OF CHILDREN. 

however, be employed with discretion, for the patient if weakly 
seldom obtains a proper reaction unless special precautions be 
taken. If the child looks blue or feels chilly after the bath, 
the shock to the system has been too violent. For a weakly 
child the cold douche should always be given in the following 
way : On rising from his bed the child is thoroughly sham- 
pooed all over the body, using steady friction, especially to the 
back and loins. His skin being thus stimulated and prepared 
to resist the shock of the cold water, the patient is made to sit 
in a few inches of water as hot as he can conveniently bear it^ 
and then immediately a pitcher of cold water (55° to 60°) is 
emptied over his shoulders. He is then at once removed, and 
well rubbed with a rough towel to assist reaction. In winter 
the bath should be placed before the fire, and every care should 
be taken to make the process a rapid one. The shampooing 
will occupy from ten to fifteen minutes, but the douche should 
be over in as many seconds. It is well to allow the child a 
drink of milk or a biscuit before beginning the process ; and 
when dried the child may return to his bed for a short time if 
thought desirable ; but after one or two repetitions of the bath 
this precaution will be unnecessary. So employed, the bath 
must be regarded purely as a therapeutic agent, and not as a 
cleansing process. The body may be washed in the ordinary 
way at night before the child is put to bed. 

"' The cold douche is of great service in all cases of weakness^ 
whether this be due to acute or chronic illness, and is only in- 
admissible if the lungs are actively diseased or there is fever. 
It is especially useful in cases of long-standing derangement 
and in the scrofulous cachexia, and may be recommended 
without hesitation for children of very fragile appearance. In 
addition to its tonic effect the bath has another valuable 
quality in that it strengthens the resisting power of the body 
against changes of temperature, and lessens the susceptibility 
to cold." 

The wet sheet pack is a valuable means of exciting diapho- 
resis, as in post-scarlatinal dropsy, and for equalizing the circu- 
lation under any circumstances. It should be given in the 
following manner: The bed is first prepared by being spread 
with several layers of woolen blankets. Then while the child 
is being stripped an attendant should wring out a cotton sheet 
which has been immersed in a bucket of boiling hot water. 
The water must be very hot or the wet sheet will be cold before 
the patient can be wrapped up in it. The sheet should then 
be quickly spread on the open blankets and the child wrapped 
up in it, leaving only the head exposed. Now the blankets 
should be brought over and tucked in all around as snugly as 



THERAPEUTIC HINTS. 25 

may be. A cloth wet in cold water should be placed on the 
head and left there as long as the pack is continued. 

The duration of the pack is to be decided by circumstances. 
It may last from fifteen or twenty minutes to an hour or 
more. If the child drops asleep it may be left undisturbed un- 
til it awakens. When taken out the cool sponge should be 
used, or the douche, as described above." 



CHAPTER III. 

DISEASES AND ACCIDENTS IMMEDIATELY FOLLOWING BIRTH. 

We have already referred to the changes which take place in 
the circulation at the moment of birth, and this momentous 
change from a dependent, parasitic life to an independent exist- 
ence is usually inaugurated without trouble or accident. But 
it is not always so. Occasionally the lungs fail to expand and 
the mother's heart fails to be gladdened by the sound of the 
first cry of the new born. 

Sometimes the child, the victim of disease or starvation in 
utero, is born in such a state of debility as to be too weak to 
cry. Sometimes it is apparently dead and sometimes really so 
— still-born. In cases of asthenia, the infant lacks the red color 
of health and is pale, at times blue; its features are shrivelled 
and its body emaciated. Under these circumstances it would 
be quite improper to subject the weakling to the same treat 
ment that would be appropriate for the strong and healthy. 
At times this state of debility is so great that it is best to post- 
pone the washing and dressing, which otherwise should be done 
as soon as practicable after birth. All that can be done is to en- 
velop it in hot flannel, or better still in hot carded cotton or 
wool. If, however, the child is not too weak it may be greased 
and washed — a little whisky or alcohol being added to the 
water, which should be as hot as can be borne, say i io° to 120° 
Fahrenheit. 

These feeble infants bear a very high degree of heat. All 
obstructions to respiration should previously have been re- 
moved by carefully wiping out the buccal cavity, and if there be 
any suspicion of obstruction in lar3mx or trachea, the expedi- 
ent may be resorted to which is often successful, to hold the 
child by the lower extremities, with its head down, and then 
to shake it briskly, or spank it sharply on the nates ; a sud- 
den inspiration is thus evoked, followed by a cough which may 
remove the whole trouble. 

If this fails, measures should be taken to increase as speedily 
as possible the strength of the child until it can take a full in- 
spiration. To this end stimulating nourishment should be 
given, a little at a time, but frequently. 
(26) 



DISEASES FOLLOWING BIRTH. 27 

A little cream, diluted with hot water to which a little whisky 
may be added, is best. The child is too weak to nurse, and yet 
it must have food. A teaspoonful of whisky or brandy may be 
added to five or six teaspoonfuls of hot water, slightly sweet- 
ened, and this given ever>^ few minutes in half-teaspoonful 
doses for a time. In this way some of these lives may be saved. 
But unfortunately others will fail to respond to the stimuli and 
become colder and colder, and bluer and bluer ; their respira- 
tion becomes more and more feeble, until it finally ceases 
altogether. 

But besides these cases of feebleness at birth, it sometimes 
happens that a child plump, well nourished and perfectly 
formed is still-born, due to a state of asphyxia from compres- 
sion of the umbilical cord or from breech presentation ; from 
premature detachment of the placenta, or other accidents in- 
cidental to labor. 

Sometimes an apoplectic condition of the child is found — a 
congestion of the brain and the blood vessels leading thereto 
producing a paralytic condition of the respiratory nerves, which 
under these conditions fail to respond to the stimulus of the 
air after being brought into the world and prompt measures 
must be employed or apparent death may speedily becomie an 
actuality. The signs of this condition are swollen features and 
face red or purplish blue. When this condition is observed and 
the child does not breathe, no time should be lost in letting a 
few drops of blood escape from the cut extremity of the cord. 
This expedient tends to relieve the congestion of the brain and 
to equalize the general circulation. 

Brisk rubbing of the body should next be resorted to ; slap- 
ping the nates ; plunging the body alternately into hot and cold 
water ; and if these means fail recourse must then be had to ar- 
tificial respiration. This is best accomplished as follows : The 
child should be placed on its side in such a position that the 
epiglottis falls forward ; a towel or napkin should be wrapped 
around the child's mouth, leaving an opening through which 
the operator can blow his breath. In the meanwhile compres- 
sion should be made on the epigastrium. A little air, notwith- 
standing the compression, will enter the stomach, and some will 
escape by the nostrils, but the rest will enter the lungs. Im- 
mediately the hand, passing from the epigastrium to the thorax, 
compresses it gently, though with sufificient force to produce 
expiration. This should be repeated six or eight times per 
minute. Very soon in many cases the heart's action, previousl}^ 
slow or almost imperceptible, will be quickened and resuscita- 
tion will sometimes be successful, even when the heart had 
ceased to beat for a considerable time. The physician should 



28 THE DISEASES OF CHILDREN. 

not abandon hope in these cases until artificial respiration has 
been continued for at least half an hour. Dr. Penrose cites a 
case when success rewarded effort after an hour and a half,"^ It 
matters not how small the proportion of these cases respond to 
our efforts, the duty is imperative and the number of resusci- 
tations is sufficiently large to encourage our hopes and 
stimulate our zeal. 

Caput Succedaneum; Cephalhematoma. — Extravasation 
of blood into that part of the scalp which presents during birth 
occasionally occurs, owing either to the duration of the labor 
or the intensity of the uterine contractions. The term "caput 
succedaneum," is the term employed to designate the swell- 
ing on the head when thus caused. Its seat is in the loose 
connective tissue of the scalp, and is external to the pericra- 
nium. The tumor is soft, painless and usually located upon 
the occiput. It consists mostly of serum or serum mixed with 
extravasated blood. This exudation, being in the loose connec- 
tive tissue as just stated, produces no discomfort to the child 
and except its unsightliness is a matter of little moment. It is 
quickly absorbed and usually does not last more than two or 
three days. It does not require any treatment. 

A somewhat different condition exists in what is called 
cephalhematoma. Here the blood and serum are extravasated 
under the pericranium as well as above it, and we not only have 
the caput succedaneum just described, but underneath it a 
tumor which is observed when the other declines. It is usually 
found upon the occipital or parietal bones, near the posterior 
fontanels. Being situated under the pericranium, it separates 
this from the bone, but owing to the resistance it meets with 
in the firmly attached membrane, it does not spread far and 
rarely crosses a suture. This tumor is not so readily absorbed 
as the former, and is therefore more permanent, not disappear- 
ing oftentimes for several weeks. Indeed, after the lapse of 
several months a slight prominence may be detected, indicat- 
ing the seat of the tumor. This is occasioned by the fact that 
the pericranium does not lose its vitality from being separated 
from the bone, but continues to perform its functions and a 
ring of new bone formation is the result. This can be readily 
detected by the finger, as it surrounds the base of the tumor. 
This new bone is thin and flexible at first, but becomes firmer 
as absorption goes on. It ultimately disappears, leaving only 
a faintly defined thickening over its seat. 



■ See Cyclopedia of Diseases of Children, vol. i, page 249, 



UMBILICAL HEMORRHAGE. 29 

Umbilical Hemorrhage.— Besides the profuse and even 
fatal hemorrhages which occur at birth or soon after from care- 
less ligature of the umbilical cord, there is another form of um- 
bilical hemorrhage in which the accoucheur is in no wise 
responsible. Over three hundred cases of the kind have been 
reported from time to time in the various medical journals and 
reports, and their causes have been studied by such accurate ob- 
servers as Dr. Francis Moriat, Prof. Stephen Smith and Dr. J. 
Foster Jenkins. Their investigations brought out the following 
results : 

''Causes. — The common proximate cause is feeble coagulabil- 
ity of the blood. In the normal state, when the cord is ligated, 
the fibrin of the blood, which now ceases to flow in the umbil- 
ical vessels, forms coagula so firm that, by the time the cord is 
detached, hemorrhage is impossible. But in the majority of 
those affected with this disease, the clots are so soft and loose 
that they do not present any effectual barrier in the pressure 
of blood, which therefore oozes through them or presses them 
away. This lack of coagulability is easily demonstrated, for if 
a little blood, as it escapes, is caught in a vessel, it will be found 
to remain liquid a long time. This dyscrasia, or morbid state 
of the blood, which we therefore recognize as a chief cause of 
the hemorrhage, does not have the same origin in all cases. It 
is sometimes due to inherited syphilis. The infant affected 
wdth it may be plump, and appear well at birth, but in most in- 
stances, when the hemorrhage is to occur, it is puny and ca- 
chectic, exhibiting also local manifestations of the disease w^ith 
which it is affected. Thus, in a case in my practice, the infant, 
puny and apparently born before term, was observed to have 
several blebs of pemphigus on the first day, from some of which 
blood began to ooze, but the fatal umbilical hemorrhages did 
not commence till after tw^o weeks. 

"In about one-fifth of the cases ecchymoses or petechie have 
been observed upon various parts of the surface, affording ad- 
ditional proof of the general blood disease. 

" Jaundice is another cause of impoverishment of the blood in 
the new-born, and therefore of umbilical hemorrhage. The 
writers who have collected records of the hemorrhage, all re- 
mark the frequent occurrence of the icteric hue, both before 
and during the bleeding. It is not improbable that, in certain 
instances, the jaundice is hematogenous, arising from destruc- 
tion of the red corpuscles and liberation of the hematin, a not 
unusual result of a profound dyscrasia, whether syphilitic or 
originating in some other cause. But in other, and probably 
most instances, the jaundice proceeds from the liver, and is 
the cause of the change in the blood. Thus, in five of Jen- 



30 THE DISEASES OF CHILDREN. 

kin's cases, there was occlusion of the hepatic or common bile- 
ducts, and jaundice, from the presence of biliary acids in the 
blood, causes diminution in the amount of fibrin and red cor- 
puscles. In the ordinary form of icterus neonatorum, the cause 
of which is found in the relative fullness of the capillaries and 
minute bile-ducts in the acini of the liver, the coagulability of 
the blood must evidently be impaired in proportion to the de- 
gree and duration of the jaundice. 

" Poor health of the mother, and impoverishment of her blood 
during gestation, whether from chronic disease, as tuberculosis, 
or anti-hygienic conditions, also cause impoverishment and 
diminished coagulability of the blood of the child, and are 
therefore causes of the hemorrhage. The excessive use of 
diluent drinks or alkalies by the mother is believed by some to 
have a similar effect. 

" In certain cases the hemorrhage is due to an inherited hem- 
orrhagic diathesis. In nine of Jenkins' cases the mothers 
were subject to menorrhagia, and liable to bleed freely after 
parturition, and from injuries ; and seventeen other mothers 
had each lost more than one infant from umbilical hemorrhage. 
Probably in those cases in which the hem.orrhage commences 
before detachment of the cord, and external to its point of 
insertion, the hemorrhagic diathesis is the main cause of the 
flow. 

"Although the cause of umbilical hemorrhage in the majority 
of cases is the vitiated state of the blood itself, observers, 
among others the late Sir James Y. Simpson, have met with 
cases in which the hemorrhage was referable to the state of 
the vessels. In order that the vessels be effectually closed by 
the fibrinous coagula, their walls should have their normal con- 
tractility, but this is in great part lost, by inflammation (arter- 
itis or phlebitis) which sometimes occurs in these vessels, as 
we have already seen. Inflammation, whether of artery or 
vein, causes thickening and infiltration of its parietes, loss of 
tone on the part of the fibres of which they are composed, 
and therefore, a patulous state of the vessel ; moreover, the 
inflammation is apt to be suppurative and the presence of pus 
in the vessel obviously hinders the formation of a firm and 
effective coagulum." 

Symptoms. — Ordinarily, umbilical hemorrhage occurs without 
any premonition, but sometimes it is preceded by jaundice. 
Jenkins ascertained that jaundice was a prodormic symptom in 
41 out of 178 cases, and besides the icteric hue, constipation, 
clay-colored stools, deeply-tinged urine, etc., were sometimes 
recorded. Rarely colicky pains and vomiting preceded the 
hemorrhage. The blood may be arterial or venous, or both. 



UMBILICAL HEMORRHAGE. 31 

It oozes slowly or rapidly, rarely escaping in a jet, even where 
there is reason to believe that it is arterial. 

Prognosis. — This is unfavorable. Statistics show that five 
in every six perish. The prognosis is most unfavorable when 
jaundice or purpura is present. Those are most likely to re- 
cover who have a healthy parentage, no obvious dyscrasia, and 
in whom the hemorrhage occurs late and is not profuse. The 
average duration of the hemorrhage in 82 fatal cases in Jenkins' 
collection was three and one-half days, the minimum being 
three hours. After the arrest of the hemorrhage death may 
occur from exhaustion or the dyscrasia. 

Treatment. — But little can be done for these cases medicin- 
ally. The bowels, which are usually constipated, should be 
kept open by enemata, and the jaundice treated by the reme- 
dies suitable to that condition. The modes of treating the 
bleeding parts have been various. Those most deserving of men- 
tion are the following : Injecting a styptic into the open ves- 
sels, applying a styptic by compress or sponge to the navel, 
covering the navel with dry or wet plaster of paris, constant 
pressure with the finger, which is tedious, but which maternal 
solicitude willingly provides, and lastly, the use of needles 
with ligature. All of these methods have been more or less 
successful in arresting the hemorrhage, but the last is most 
effectual, though painful. Two needles should be passed 
through the umbilicus at right angles, and a waxed thread 
wound around each in the form of a figure eight. In four or 
five days the needles should be removed and a poultice or sim- 
ple dressing applied. 



CHAPTER IV. 

FOOD AND FEEDING. 

Every new-born child, when it comes into the world, brings 
with it an iteration of the old problem, "wherewithal shall it 
be fed ? " and we cannot avoid the question long, for if the babe 
be healthy, it will soon cry aloud for sustenance. The fires of 
life must be kept burning ; its ever wasting secretions must be 
made good ; material for repair and for growth must be con- 
stantly provided, or the organism will soon perish. When the 
mother is in good health and has an adequate supply of milk, 
or when in lieu of this, a young and healthy wet-nurse can be 
secured, the question of nourishment is easily settled, for there 
is no diversity of opinion as to the advantage of breast milk, 
and its superiority over every other kind of food, always pro- 
vided, however, that the milk furnished by the breast of the 
mother or the wet-nurse proves on trial to agree with the child. 
Be it known that it is not every woman whose milk agrees with 
a new-born babe. We have a case in mind that very clearly 
demonstrates this fact. Some years ago we attended a woman 
some thirty-five years of age in her third confinement. The 
babe was born at full term, and was a strong, plump, ruddy in- 
fant. The mother was a type of physical health and strength. 
She had ample breasts with well-formed nipples, but she in- 
formed me that she could not nurse her children. I learned 
from her that her first child was a puny weakling during all the 
time she nursed it, and did not thrive and grow until after it 
was weaned when a year old ; her second child, although large 
and plump at birth, was nursed by her until it died at eight 
months of age. It declined steadily from the time it was born 
until death. Notwithstanding this discouraging history, I 
urged her to try it again, and she readily agreed to make the 
experiment. In due time she had an abundant flow of milk, 
and I had it carefully analyzed. Not a fault could be found 
with it. It was up to the standard in every respect. The babe 
took the breast eagerly, and for a week all went well. It neither 
gained nor lost in weight ; but in the second week it became 
fretful and peevish, cried almost continually, and lost a pound 
in weight. Again I had the milk analyzed, with the same re- 
sult as before. It answered to every test, and was pronounced 
(32) 



FOOD AND FEEDING. 33 

perfect in every respect. But the baby steadily lost ground, 
and at the end of three weeks was put on artificial food. It 
was not until after six months that it began to grow and thrive 
as it should. It is now, however, at the age of eight or nine 
years, a strong, full-sized and healthy girl. I learned a lesson 
from this case that has been of much service to me since then, 
viz., that the baby is itself the best and the only sure test of 
food, whether it be natural or artificial. Indeed, the funda- 
mental principle of feeding is to adapt the food to the wants 
and the capacity of the individual infant. It will not do to 
have any rigid and inflexible rules. Precedent is apt to mis- 
lead ; tables of nutritive equivalents are worthless ; chemical 
analysis is valueless. 

There is a vital chemistry which is too subtle for the labora- 
tory ; changes and physical alterations occur in food which are 
too delicate for tests or analysis ; and yet they make all the 
difference between digestion and indigestion — between assimi- 
lation and non-assimilation — between life and death. Trial is 
the only touchstone, experiment the only guide that will lead 
us in safe paths. That organic chemistry is incompetent to 
pass on the question of foods at all times — that it is liable to 
mislead at any time unless its physiological peculiarities are also 
considered, is evident from certain well-known facts. For ex- 
ample, milk that has undergone change, that is " turned," is re- 
garded, and very justly so, as unfit to be taken into a baby's 
stomach as food ; and yet, no sooner is fresh, sweet milk taken 
into the stomach than lactic acid is formed and the milk is 
^'curdled." 

The milk is not assimilable until this change takes place ; 
but it must take place within the stomach and not out of it. 
Again, chemistry teaches us that all foods are divisible into 
the nitrogenous and non-nitrogenous, and that the former 
are the plastic or tissue-forming elements, while the latter 
are respiratory or heat-producing merely. The natural in- 
ference is that the one class of elements is far more essential 
to the organism than the other. And yet the fact is that 
not a cell nor a fiber can be formed, nor can they subsist, 
without a certain amount of fats and salts. Not a tissue 
can come into being, nor continue its functions, without a 
large proportion of 72^;/-nitrogenous materials — a propor- 
tion greatly exceeding the nitrogenous. If the proteids are 
a si7te qua 7ion, so also are fats, water and salts. When 
chemistry teaches, as it does, that *' only nitrogenous 
substances are capable of conversion into blood," it 
teaches a palpable fallacy and leads us at once into a maze 
of error. 

D. C— 3 



34 THE DISEASES OF CHILDREN. 

We have said this much to illustrate the statement that, be- 
cause the milk of the mother or the wet-nurse is able to pass 
muster when subjected to chemical analysis, it does not there- 
fore follow that it must and does fulfill all the requirements 
for the nourishment of the new-born child. The child's stom- 
ach offers a better and higher test. 

Such instances as that narrated, when not only one but seve- 
ral children have failed to be nourished by the milk of a robust 
mother, are exceptional, but they do occur and it is proper the 
student and the young practitioner should be made acquainted 
with the fact. Other cases there are, and these are far more 
common, where mothers are fully able and willing to nurse their 
offspring, but who should never be permitted to do so, if the 
future well-being of the child is properly considered. The dan- 
ger of aggravating or transmitting constitutional taints through 
nursing is universally admitted. That only healthy mothers 
should nurse their young is so palpably true that the bare state- 
ment of the fact is sufficient. But as Dr. Jacobi well says \^ 

" Health is a relative term, and the general health of the 
body is quite compatible with defective development of one or 
more of its parts. Thus, even well-formed breasts may contain 
diminutive milk glands, whose imperfection is concealed by the 
abundant adipose tissue lying under the skin. Again, the 
glands may be sufficiently large, yet their activity be continually 
interfered with by the irritable condition of the nervous sys- 
tem. . . . The evil influence of an excitable, nervous 
temperament may be manifested in the quality of the milk, 
which, under violent emotions, may be so altered as to become 
a positive poison to the child. 

"Generally the effects of such alteration are confined to digest- 
ive disturbances, to vomiting, colic, purging. But in some 
rare instances, whose record is famous, a child put to the breast 
of a woman still agitated by violent excitement, has been seized 
with convulsions, or has died suddenly, without the warning of 
any symptoms whatever. In these cases a virulent ferment 
seems to have been generated in the milk, analogous in the in- 
tensity of its action to that formed in the saliva of a hydropho- 
bic dog, and whose malignancy varies according to its abun- 
dance and to the mass of milk that had been decomposed under 
its influence. 

*' For these reasons, a woman with a markedly nervous tem- 
perament is generally unsuitable for the office of nursing, since 
her milk is liable to become deficient in quantity or perverted 
in quality." 



*" Infant Diet,' 



WOMEN WHO SHOULD NOT NURSE. 35 

Where the child is born with a. harelip or a cleft palate, there 
is an impediment to nursing on the part of the child that is in- 
superable. To understand this it is necessary to comprehend 
the mechanism of suction. 

Again we quote from Dr. Jacobi: ''When the child seizes the 
nipple, the lips, fitting accurately around it, close the cavity of 
the mouth in front, while behind, this cavity is closed by the 
soft palate, which falls like a curtain upon the root of the 
tongue. The tongue arches so as to touch the roof of the 
mouth, and the cavity is thus completely filled up, as the cyl- 
inder of a pump is filled by the piston. When the child begins 
to suck, the tongue is drawn back, just as the piston would be, 
and for the same purpose, to create a vacuum in the space left 
between its tip and the lips. Into this vacuum the milk is forced 
by the pressure of the atmosphere on the breast. 

"As soon as the space is filled, the milk is thrown to the back 
of the mouth by the tongue, which abandons for this purpose 
its office as piston, the soft palate is lifted up to a level with 
the roof of the mouth, thus closing the communication with the 
nose, and the milk falls into the throat, there exciting automa- 
tic contractions of the pharynx, that occasion a distinct sound 
of deglutition. This movement of deglutition alternates there- 
fore with that of suction." 

When the tongue is " tied," i. e., bound down to the floor of 
the mouth, it is easily seen that the act of suction cannot be 
accomplished until the defect is remedied. It cannot retreat 
sufficiently to act as a piston. This impediment is easily re- 
moved by snipping the frcnum linguce sufficiently to release 
the tongue. This should be done with a pair of blunt-pointed 
scissors, care being taken not to cut too far back for fear of 
injuring a branch of the lingual artery. Where the mother's, 
nipples are absent, from accident or disease, or are illy 
formed, it is often a fruitless task to remedy the defect suffi- 
ciently to enable her to nurse successfully. No shield or 
artificial nipple is made that can be fully relied upon. It is 
better to abandon the effort in the beginning. This statement 
does not apply to nipples that are merely depressed, as we shall 
see presently. 

Women who Should not Nurse.— But a constitutional 
disease in the mother and some acute morbid conditions are a 
barrier to nursing that cannot be ignored. The blood of 
rheumatic women contains an excess of lactic acid, and their 
milk will inevitably create a ferment in the child's stomach 
disastrous to its health. The children of such women are 
proverbially illy nourished, undersized, thin and nervous. 



36 THE DISEASES OF CHILDREN. 

When the mother is anemic — that is to say, when her blood is 
impoverished from deprivation or overwork — the solid constitu- 
ents of the milk are necessarily diminished. The milk is thin 
and watery and more or less wanting in the essentials of full 
nutrition. Consumption, syphilis, epilepsy, scrofula, cancer, 
are all so readily transmissible as to be prohibitory if one ex- 
pects the child to grow to healthy maturity. Chronic eruptions 
should probably be put into the same category, for the obvious 
reason that out of pure blood can we alone expect pure milk. 
Mania, if it amounts to insanity, renders the act of nursing too 
precarious or even dangerous to be permitted. The essential 
fevers, if of a mild type, which do not affect the mother's rea- 
son, nor interfere with the flow of milk, need not interfere with 
the performance of the functions, especially if they be not so 
prolonged as to greatly exhaust the strength and imperil life. 
Erysipelas is a disease that appears to affect the milk badly 
and render it unfit for nursing. There are cases recorded of 
this disease occurring during lactation in which the results to 
the infant were fatal. 

Suppurative inflammation of the breast offers sufficient rea- 
son for suspending its use, at least until the milk secreted by 
it is free from pus. In cases where the nipple is cracked or 
fissured and a secretion of pus takes place, this also is a suffi- 
cient reason why nursing should be interdicted until the 
trouble is cured. This can usually be effected by the frequent 
application of the compound tr. of benzoin, or tr. of calen- 
dula. Washing the nipple frequently with a solution of borax 
will often prove serviceable. Primipara should be instructed 
to apply some astringent to their nipples daily during the last 
month or so of their pregnancy, in order to harden them and 
prepare them for the application of the child's mouth which, 
under neglect, is sometimes at first very painful. At the 
same time this is done traction should be made on the nipple 
with the fingers in cases where this organ, which is so essential 
to the proper performance of the function, is depressed or 
retracted. Even in bad cases of depression, a fair nipple can 
be developed by persistent and intelligent effort. 

The Goodyear breast-pump, if properly and persistently used 
for a month or more before confinement, will, by the suction 
which is brought to bear upon the depressed nipple often de- 
velop an otherwise useless organ into one which may answer 
every purpose. A common clay pipe with its edges made 
smooth is another expedient which is frequently resorted to 
with success. 

Where this matter has not been attended to prior to the 
birth of the child, the primipara should be encouraged to hope 



MENS TR UA TION A ND PREGNA NC T. 37 

that as the infant grows stronger its natural effort will succeed 
after a time in overcoming the defect and develop a nipple that 
will answer all necessary purposes. 

Women who have never suckled, become very impatient 
and nervous when they discover their inability to perform the 
act at once, and become feverish and excited, which has a del- 
eterious effect upon the milk. Such women should be assured 
that in all probability, the difficulty will pass away in a few 
days or a week, and that their unremitting efforts to nurse at 
the expense of rest and sleep are detrimental both to mother 
and babe. 

While waiting for the young infant to gather sufficient 
strength to draw out a serviceable nipple the desired object can 
often be expedited by calling in the service of an older and 
stronger nursling, who by its more vigorous efforts and greater 
experience may be able to seize the nipple and develop it. It 
is every way essential to successful nursing that the mind of 
the young mother should be calm and placid. Anything which 
creates apprehension or interferes with repose militates strongly 
against the function of lactation and renders both mother and 
child ill. 

Menstruation and Pregnancy. — There is a diversity of 
opinion among authors as to the effect of menstruation upon 
the mother's milk and thence upon the child. On the one 
hand, it is claimed, that if any disturbance is felt by the nurs- 
ing infant, at the first return of the menstrual flow, it is ordi- 
narily attended with but little, if any serious effects, w^hich are 
not only trifling in character, but brief in duration ; that the great 
advantages to the child from having the breast, especially to fall 
back on in case of sudden illness, far outweighs the disadvantages 
and dangers. It is also claimed that the milk is so little changed 
in quality even during the flow that its effect on the child's nu- 
trition and growth is inappreciable. On the other hand, it is 
stated on good authority that in many cases the indigestion 
which is set up at this time is or may be serious ; that vomit- 
ing and diarrhea are not at all exceptional, and even more dan- 
gerous symptoms are not uncommon. My own observation 
leads me to think that few women can carry on the two func- 
tions successfully at the same time. I am sure that this is so 
when the menstrual flow is excessive or unduly prolonged ; or 
again when it is attended with much pain and general constitu- 
tional disturbance. Under these circumstances the nursing 
babe is almost sure to suffer more or less from some gastric dis- 
turbance, which is apt to continue until the flow is over, or at 
least for a day or two. It matters not that chemical analysis 



38 THE DISEASES OF CHILDREN. 

shows that, ordinarily, the miik is but Httle altered in its physi- 
cal composition. The fact that the baby shows it in colic and 
diarrhea, feverishness and fretting, is evidence enough that tem- 
porarily at least the milk is a cause of disturbance, and I have 
seen numerous cases where this condition was noticeable at 
each return of the menstrual epoch. 

Our plan of late has been to advise weaning at the second re- 
turn of the menses, unless there was something in the season 
of the year or other good reason for deferring it till a later 
period. It may be advisable in some cases, especially when 
the mother's milk has been agreeing with the child heretofore, 
to only partially wean it ; giving it the breast in the intervals 
between the menstrual periods and feeding by bottle during 
the flow. 

As to the effect of pregnancy on the function of lactation, 
there can be no two opinions. No woman can nurse a babe at 
the breast and do justice to another in her womb at the same 
time. One or the other — and commonly both — must inevitably 
suffer. As soon as pregnancy takes place in the nursing woman 
there is a diversion of some of the solid constituents of her 
milk to help in the formation of the fetus in utero. Her milk 
becomes thinner and more watery and the nursing babe begins 
to decline in weight and spirits. 

A prolongation of the function under the circumstances is 
almost certain to result in a rickety child. 

It will be a matter of good fortune if it does not result in two 
of them. Under certain circumstances, such as extremely hot 
weather, it may be deemed best to postpone weaning for a few 
weeks; but if a competent wet-nurse can be procured this is far 
preferable and far safer. No child should be weaned in the 
city during the extreme heat of summer, no matter what its 
age or the necessities which render the weaning expedient. 
All experience goes to show that summer complaint and cholera 
infantum are vastly more common during summer in the 
city than in the country, and a child just weaned is much 
more liable to these diseases than one accustomed to a mis- 
cellaneous diet. 

Scantiness of Milk and Partial Feeding. — The exact 
amount of nourishment required by a healthy infant in each 
twenty-four hours can only be approximated. Some children 
take a great deal more than others and some women have a 
much more copious secretion than others. There is no fixed 
rule by which the quantity can be gauged or by which we can 
tell whether the secretion is ample for the needs of the infant 
except that test which we have spoken of before — the test of 



SCAJVT/A^ESS OF MILK. 39 

experience. If the infant takes a. proper amount of sleep — if 
it drops asleep habitually after nursing and has a long nap — if 
its color is normal and it seems happy and contented — if in 
addition it is perceptibly growing in weight, it is fair to pre- 
sume that the milk is abundant in quantity and satisfactory in 
quality. If, on the other hand, the child is restless and fretful 
and soon exhausts the breast without being satisfied ; if it wants 
to be nursing all the time and does not show evidences of 
growth and contentment, the inference is a just one that the 
milk is defective either in quality or quantity. Unless there 
are evidences to the contrary, it is fair to presume that it is the 
latter rather than the former. The signs of a good nurser will 
be mentioned in the next paragraph. 

When the deficiency of milk is manifest, and we have reason 
to believe the quantity to be good as far as it goes, we should 
endeavor to increase the flow of milk by such means as may be 
at our command. There are two opposite conditions which 
militate against the due quantity of milk as well as its quality. 
They are the conditions of anemia and plethora. Either con- 
dition will disorder the secretion and yet both are amenable to 
treatment. The anemic woman should have a more generous 
diet, take plenty of exercise in the open air and by every means 
build up her general health. The other condition, that of hy- 
peremia, is more commonly met with in wet-nurses who, by 
reason of their new vocation, have suddenly risen from want to 
af^uence. A woman of the poorer classes, who is admitted into 
a Vv-ell-fed household where plenty abounds, is very apt to grat- 
ify her appetite to the extent of gormandizing. If given all 
she wants, she will soon surfeit herself and become too plethoric 
for the proper performance of her duties. 

Her breasts may increase in size, but mainly from a deposi- 
tion of fat. The treatment of such cases is too obvious for 
comment. When a mother finds her milk deficient in the first 
few days of lactation, she should be encouraged to persist in her 
efforts to nurse, notwithstanding the small amount of secretion, 
for nothing so stimulates the flow of milk as suction. 

The babe should be put often to the breast, and if it lacks 
sufficient strength to bring about an abundant flow, the breast 
pump may be employed as an auxiliary, and the milk thus ex- 
tracted fed to the infant. The use of electricity is oftentimes 
very beneficial. The Faradic current is the one we have usually 
employed, and the one we regard as most efficacious. The fact 
is now well established by physiological experiments that 
glandular organs can be made to secrete more actively by the 
stimulus of electricit}^ and its clinical employment as a galac- 
tagogue affords ample proof of its efficacy. We have ver}' ma- 



40 THE DISEASES OF CHILDREN. 

terially promoted the secretion in numerous cases and regard 
it as superior in general to all other means. 

In employing electricity for this purpose we apply the posi- 
tive pole — the sponges being well moistened with warm water 
— to the hypogastric region just over the solar plexus, and the 
negative over the mamme, moving the electrode about con- 
stantly during the application. After the current has been 
applied for from three to five minutes, the poles may be placed 
on and around the breasts, so as to direct it through them from 
side to side. The current should be as strong as can be borne 
without discomfort. 

In spite of all our efforts we frequently fail to establish an 
adequate secretion of milk to meet the wants of the insatiate 
infant, and we are confronted with the question whether the 
mother, with only a partial supply of nutriment, should con- 
tinue to nurse the child, giving it all she is able, and supple- 
ment this with artificial food, or abandon nursing altogether. 
There is a popular notion — a fallacy, as we regard it — that 
mixed food is not likely to agree with the average child. How 
this prejudice against combining suckling and hand-feeding has 
happened to become so widespread is a mystery. It surely is 
illogical and contrary to clinical experience. If human milk 
and cow's milk fail to agree when they commingle in the child's 
stomach and create a disturbance there, it surely is not the 
mother's milk that is to blame, provided her milk is healthy, 
and quantity is its only fault. The cow's milk may disagree^ 
but rarely the mother's. All that the child can get of this, the 
better ; it is pure gain. It may be that the child is unable to 
digest cow's milk, or any of the other artificial foods that are 
presented in the way of substitute for the deficiency, but this 
is all the more reason why it should have as much mother's 
milk as it can get ; for this it can digest, and half a loaf is better 
than no bread. 

The diet of a nursing woman should be generous without 
being rich. She should, if her supply of milk is at all deficient, 
drink freely of cow's milk and good, nutritious soups. Oat- 
meal and barley gruels are most excellent milk-makers, and 
plenty of fluids should enter into her dietary. This does not 
mean that her entire food should be of the '' sloppy " order, for 
she may eat with reasonable freedom of all that experience has 
taught her to regard as wholesome. She should avoid spices 
and all forms of condiments, and such articles of food and drink 
as are over stimulating. She need not abstain from acid fruits, if 
she is fond of them, and finds on trial that they do not disturb 
the baby's stomach. 

Theoretically, fruit acids ought not to disturb the digestion 



SELECTION OF A WET-XCI^SE. 41 

of any nursing child, for in physiological digestion, long before 
the acid which is taken into the stomach of the mother can 
reach the milk glands through the blood, it is changed into 
alkalies, and is therefore harmless. Here is another instance, 
however, where practice turns its back on precept. Theory is 
one thing, and practical experience is quite another. In spite of 
the theory it is found that these acids do find their way into 
the milk, and gripe the baby whenever they are eaten. When 
this is so, they should be avoided, as well as all other articles of 
food that produce colic. 

The use of beer and all fermented drinks by nursing women 
is to be deprecated. Their use as promoters of lactation 
is a delusion and a snare. Anemic women whose appetite is 
poor, may take ale or porter once or twice a day if it agrees, 
but neither of these should be relied upon to the exclusion of 
better things. These pallid mothers require a larger propor- 
tion of animal food than women in good general health ; while 
plethoric women with large appetites should restrict themselves 
to a diet more farinaceous. Various medicines have been em- 
ployed to increase the lacteal secretion, but we know of none 
that has any claims worthy of mention. What remedies are 
taken should be directed to improve the general health, with- 
out regard to their direct effect on the milk supply. 

Since writing the above, our attention has been called to a 
galactagogue which seems to possess considerable merit, and in 
the few cases in which we have used it, it has certainly increased 
the milk flow materially. 

We refer to " Nutrolactis," prepared by the Nutrolactis 
Company, of New York. It is made from the fluid extracts of 
the plants Galega Officinalis and Galega Tephrosea — three parts 
of the former to one part of the latter. It is claimed that the 
use of this combination will greatly increase the quantity of 
milk in all of its essential elements, and maintain a sufficient 
flow during its employment. 

The Selection of a Wet-Nurse.— The introduction of 
a wet-nurse into a family sometimes becomes a necessary evil. 
We speak advisedly, for evil it proves to be so often in the 
course of a physician's experience, that he comes to regard it 
as more often than otherwise the opposite of a divine blessing. 
Still the necessity frequently arises, and the responsibility of 
selection is placed upon the physician in charge. I can scarcely 
conceive of a duty more onerous. The class of women who 
offer themselves for this kind of service is naturally open to 
suspicion in everyway. Self-interest dictates the concealment 
of all impediments and disabilities. The physician should re- 



42 THE DISEASES OE CHILDREN. 

gard it as his bounden duty to subject them to the most rigid 
investigation. If the infant of the woman offering herself as a 
wet-nurse can be seen, it will aid materially in deciding the 
question of her qualifications. In lieu of this, a certificate from 
the doctor who attended her in her confinement, is of much 
value. Even references from her employers, if she has pre- 
viously been at service, may aid in the investigation. By per- 
sonal inspection and otherwise the exact state of her health 
and the quantity of her milk should be ascertained. Other 
things being equal, the best wet-nurses are in general appear- 
ance, robust without being corpulent. They have a clear skin 
and a good complexion. Their breasts are full without being 
fat and tortuous veins are observed passing over them. Some 
wet-nurses give abundance of milk and that of the best quality 
whose breasts are small. These women appear to secrete their 
milk mainly during the time of suckling and it is a well-estab- 
lished fact that the richest milk is that which is newly secreted. 
The longer the milk remains in the breast the thinner it becomes. 
The loss of milk, habitually, by oozing is not a good recom- 
mendation for a nurse. It generally indicates a relaxed condi- 
tion of the system, or a tendency to other fluxes of various 
kinds. It is a sign of weakness rather than of strength, and 
bears no relation as a rule to the abundance of milk retained. 
In selecting a wet-nurse attention should be given to the nip- 
ples to ascertain if they be well formed and prominent and 
free from excoriations and fissures. The presence or absence 
of colostrum should also be determined. There should be no 
colostrum after the eighth or ninth day in good milk. If there 
is colostrum present, as indicated by microscopical examina- 
tion, it is probable that there is some fault in the health or the 
digestion of the wet-nurse, and that her milk may disagree with 
the infant. A simple test will determine approximately the 
richness of the nurse's milk. If a quantity of it be placed in 
a test tube and allowed to stand undisturbed for a time, the 
amount of cream which rises to the top should be about three 
per cent, and the casein and sugar are usually about the same 
in quantity as the cream. Milk which answers to this test may 
be regarded as up to the usual average. 

The milk of a wet-nurse whose own child is not over six 
months of age will usually agree with a new-born infant. It is 
desirable that the wet-nurse herself should be under thirty 
years of age rather than over ; and if she has previously suckled 
and had charge of infants it is an added advantage, for such a 
one has gained at least something in knowledge by her experi- 
ence. Where several candidates for the position of wet-nurse 
present themselves, preference should be given, other things 



DIRECTIOXS FOR XCRSIXG. 43 

being equal, to the one who is most tidy and cleanly. A 
woman who is slovenly about her clothing is generally careless 
about her person, and in either case her value in the house- 
hold is depreciated. 

DiRECTlOXS FOR NURSING. — After the mother has had a 
few hours' rest and has sufificiently recovered from the fatigues 
of labor, and after the toilet of the new-born babe has been 
duly made, it should be applied to the breast. The small 
quantity of milk which it will find there is usually enough to 
satisfy its first craving, and the act of nursing promotes further 
secretion. The infant is so constituted that it does not re- 
quire much food during the first few days after birth, for other- 
wise nature would provide for its needs sooner than she does. 
In point of fact, the full secretion is not established as a rule 
until the third day, so that, however often the child is placed at 
the breast, it obtains but little, and that little is colostrum rather 
than milk. The practice of giving sweetened water or other 
fluids, on the supposition that the child has been starving in 
utero and is born hungry', is a great mistake. The seeds of in- 
digestion are liable to be sown in this manner which it may 
take weeks to overcome. Filling the stomach in this way has, 
moreover, a tendency to vitiate the infant's appetite and pre- 
vent it from drawing upon the nipples with the avidity which is 
necessary to stimulate a free flow of milk. Should the infant 
have nothing except what it is able to extract from the breast 
before the third day, no uneasiness need be felt on this account. 
Its stomach will be in much better condition to receive its 
legitimate food when it comes than if upset in the meantime by 
unsuitable foods. Should the child, however, refuse to be paci- 
fied, and especially if the third day comes without any increase 
of milk in the mother's breast, it will be quite proper to give 
at intervals of two or three hours a small feeding of cream and 
hot water — half and half — sweetened with sugar of milk. Cane 
and beet sugars should never be used for sweetening a baby's 
food if milk-sugar is obtainable. It is well to observe that the 
latter is not nearly so saccharine as the former, so that a larger 
quantity should be used. 

As soon as the mother finds herself in condition to supply 
the alimentary needs of her child, its education should begin. 
It should be taught the primary lesson of good digestion, viz., 
regularity of feeding. During its first month it should nurse 
about ever>' two hours during the day and twice during the 
night, or about ten times during each twenty-four hours. The 
stomach of the new born holds but little, while its digestion is 
very active. 



44 THE DISEASES OF CHILDREN. 

After the first month the intervals of feeding may be 
gradually prolonged so that by the fourth month they should 
be three hours during the day, and by the sixth month four 
hours and once during the night. By this time the child should 
begin to take some artificial food — such as barley water and 
cow's milk — a good way being to alternate this with breast feed- 
ing. The practice which is all too common of putting the in- 
fant to the breast every time it cries, even though it has just 
been fed, is extremely pernicious. It is slavery for the mother 
and a detriment to the child. 

A strong proof of the prevalent belief that every child is 
born into the world, not only with an immortal soul, but also a 
modicum of the seeds of " original sin," is found in the won- 
derful facility with which it falls into bad habits. The more 
these bad habits are fostered, the more they will grow ; and in 
due time the mother will find, to her sorrow, a practical exem- 
plification of the fact that *' They who sow to the wind shall 
reap the whirlwind." 

The infant stomach must have time to digest. It cannot 
work continuously and work well. If allowed to try the ex- 
periment anew, it will only result in indigestion, diarrhea and 
fretfulness. Systematic feeding at such intervals as will give 
the stomach time to dispose of the preceding meal will best 
subserve the interests of the child and the mother as well. 

It is not intended by this that anything like mathematical 
exactness shall be observed. There are exceptions to all rules 
and circumstances alter cases. If the infant is having a quiet 
and natural sleep when the time comes around for nursing, 
common sense would dictate an undisturbed slumber and a post- 
ponement of nursing until it should awaken. It will be wide 
awake enough when its system requires more nutriment. 

By the time an infant reaches the age of six or eight months, 
and sometimes earlier, the mother becomes more or less fagged, 
even though her menses have not yet appeared ; her milk begins 
to deteriorate and lose something both in the matter of 
abundance and quality ; at the same time the nutritive needs, 
of the infant become greater ; the teeth are beginning to come 
to the surface, and a greater amount of nourishment is now 
more needed than before. Few women are able to carry on the 
process of lactation beyond this period and meet the require- 
ments of growth and development without the supplemental 
aid of artificial, or as Cheadle calls it, *' alien " food. It is not 
necessary as yet, under ordinary circumstances, if the mother is 
strong and experiences no exhaustion from suckling, to wean 
the infant abruptly; but it is necessary to furnish some addi- 
tional pabulum to meet the new requirements. 



DIRECTIONS FOR NURSING. 45 

It is better to anticipate this need rather than to wait until 
its necessity is forced upon us. Besides this, it is better, as soon 
as the infant is of suitable age, to gradually accustom it to a 
less restricted diet than that of the breast. This age varies 
considerably. With some it may be reached by five or six 
months, while with others it may not be reached before nine or 
ten months. The mother's state of health, the infant's physi- 
cal development, the time of year — various factors enter into 
the question, and in some cases hasten and in others defer this 
and all other experiments. The addition of supplementary 
food, as just advised, is deemed expedient, partly as a prepara- 
tion for weaning entirely, which should rarely ever be post- 
poned beyond the end of the first year. It is never best to 
wean an infant during the heat of summer, nor while ill, unless 
the illness be caused presumptively by the mother's milk. 

As solid food requires a greater development of the digest- 
ive apparatus to accomplish perfect assimilation than liquid, 
the latter should be given in preference to the former, both 
with the breast milk and after weaning. Solid food, indeed, 
should not be given until the canine teeth have appeared. 
When they have come the infant should have sixteen 
teeth, and the peptic glands of the stomach be correspondingly 
developed. Even then it is better that weaning should be 
gradual rather than abrupt. The sudden change of food is apt 
to be followed by fretfulness and restlessness, while the grad- 
ual change, to an infant that for some time has been partially 
fed, is scarcely noticeable. 

As to the food most desirable and safe to give to an infant 
after being taken from the breast, we refer the reader to the 
next chapter, on Artificial Food. 



CHAPTER V. 

FOOD AND FEEDING — {Continued) 

Artificial Feeding. — Cows Milk. — When, for any 
reason, artificial feeding of an infant becomes necessary, the 
contingent problem becomes complicated and puzzling. Theo- 
retically the matter is simple enough. The principles which 
underlie the substitution of foreign or " alien " food for that 
supplied by the human breast, are as simple as the alphabet. 
The analysis of a healthy woman's milk shows exactly the 
chemical constituents of that aliment which nature herself pro- 
vides for the due sustenance of the human infant, and the reU 
ative proportion of the elements which enter into its normal 
composition. But, as we have seen already, nature does not 
make allowance for those aberrations of functional power on the 
part of the infant, and does not take into consideration the fact 
that infants are sometimes born with digestions so weak and 
imperfect that even breast-milk is beyond the powers of assimi- 
lation. There are occasional and exceptional cases in which the 
better the food the worse it is for the starveling infant. 

To the uninitiated this may sound like a paradox, but just 
such paradoxes are met with not infrequently by the experi- 
enced physician One of the fundamental principles above 
alluded to is that a portion of the daily food of an infant must 
be animal. The young of all mammalia require food that has 
previously been digested and elaborated by another and an older 
animal. Vegetarianism may be well enough for those that like it; 
but whether good or bad for adults, it will not do for infants, 
and an exclusive diet of purely vegetable food is utterly inade- 
quate to their growth and sustenance. One reason of this is 
that the infantile stomach is disproportionately small as com- 
pared with its nutritive needs. Vegetable food is far more 
bulky than animal, and hence a much greater quantity must be 
ingested to give the same equivalent in nutritive elements. 
More than this, all animal food is partly pre-digested, and but 
little more needs to be done after ingestion to render its fibrine 
and albumen or casein fit for absorption and nutrition. 

This necessity for animal food, which, in a breast-fed infant, 
is supplied by the mother or the wet-nurse, is met by the sub- 
stitution in other cases of the milk of one of the lower animals. 
(46) 



ARTIFICIAL FEEDING. 47 

Singularly enough, not one of these provides a food for its 
young which is precisely like that of the human female. The 
milk of the ass, goat, mare and cow, all show differences, both 
chemically and in the way they behave when taken into the in- 
fant's stomach. Still these differences are not very great, and 
it would seem as if art ought to be able to remove excesses and 
supply deficiencies, and make the milk of either of these animals 
approximate very closely, if not entirely, to the average of hu- 
man milk. The problem, simple as it seems, is not unattended 
with difficulties. It has been found that asses' milk is more like 
human milk than any other. But we have no establishments in 
this country, such as are found in London, where asses' milk is 
provided on a large scale for infantile needs, and other emergen- 
cies. Goats' milk, while closely resembling human milk, has a 
peculiar odor which renders it objectionable ; and since all milk 
other than human must be modified more or less to adapt it to 
the human infant, it is as easy to deal with cow's milk as any 
other. Although cow's milk when freshly drawn differs in 
essential respects from human, its defects could be easily reme- 
died if we could always rely upon the freshness of our supply. 
In the country, where this can be done, the problem is not so 
difficult of solution. But in cities and larger towns, where the 
milk is usually twenty-four, or at least twelve hours old before 
it reaches the nursery, it is a very different matter. The at- 
tempt to overcome this objectionable feature by seeking a sup- 
ply of milk from a stall-fed animal is futile. No cow can long 
maintain her health and continue to give good milk of standard 
quality, that is deprived of her accustomed exercise and changed 
in all her regular habits of life. Human milk is alkaline in its 
reaction ; so is that of a cow roaming at large in the field, 
when it is newly drawn. But the milk of a cow that is stall-fed 
is acid in its reaction, and soon falls below the standard in the 
matter of cream. 

There is a prevalent notion among the laity, that whether in 
city or country, the milk of one cow is preferable to the mixed 
milk of several cows. This is an error. Every cow's milk will 
vary from time to time and every cow is subject to many ail- 
ments which temporarily reduce her milk below the standard 
in some essential particular. The mixed milk of the dairy 
practically overcomes this difficulty, and will maintain a better 
average than that of any one cow. But the great trouble with 
dairy milk, even when served by an honest dairyman, is the 
length of time which must necessarily elapse between the milk- 
ing of the cow and the delivery of the milk. Another trouble 
is that in spite of care the milk will in most, if not all cases, be 
more or less contaminated with filth and debris, and more or 



48 THE DISEASES OF CHILDREN. 

less polluted either by the hands of the milker, the udder of the 
cow, or by impurities gathered in the course of transportation. 
Fermentative changes are thus easily and quickly set up, and 
by the time the milk is ready for use these changes may be pro- 
gressing actively. On this account the milk should be strained 
through a muslin cloth as soon as received, and then boiled for 
five minutes and bi-carbonate of soda in the proportion of one 
grain to the ounce of milk should be added, in addition to the 
boiling. The milk should then be placed in the refrigerator 
or other cool place to be used as wanted. Bi-carbonate of soda 
is to be preferred to lime water as generally recommended, be- 
cause the soda is more assimilable and much more effectual as 
an antacid. It seems illogical to take exception to the water of 
a well, that shows a precipitate of lime, and refuse to use it 
on the general table, and then go to the drug store to buy lime- 
water to put in the baby's milk. 

Furthermore, Sir W. Roberts has shown that ten grains of 
bi-carbonate of soda are equivalent in antacid power to six ounces 
of lime water, and that its effects on the milk is to produce a 
more flocculent curd, the very thing which is so desirable in ren- 
dering cow's milk like that of the mother. 

Peptonized Milk. — The principal reason why cow's milk is so 
difficult of digestion by the infant stomach, is not, as commonly 
supposed, because it contains more solid constituents than 
human milk, especially casein, but because this casein or curd 
coagulates into large masses as soon as it enters the stomach 
and the gastric juice is not sufficiently powerful to dissolve 
them. It remains there an insoluble bolus. To overcome this 
trouble, it has been proposed to predigest the milk by convert- 
ing the casein into soluble peptone outside of the stomach. 
This removes all curd difficulty and leaves the same amount of 
nutriment in the milk that was there before it was peptonized. 
But although peptonized milk is rendered more digestible than 
milk not so treated, there are serious objections to its continual 
use. The chief of these objections is, that it takes from the stom- 
ach the proper exercise of its digestive function, and the organ 
becomes enfeebled thereby. This is a serious objection and 
should prevent the use of peptonized milk for any great length 
of time. In emergencies, however, and for the purpose of car- 
rying an infant through an acute attack of indigestion from 
other causes, it is a valuable expedient. Peptonized milk has a 
perceptibly bitter flavor which makes some infants refuse it, but 
this difficulty can usually be overcome by the addition of a 
larger quantity of sweetening with sugar of milk or by using 
condensed milk, which is already highly sweetened. By using 
peptonizing powders, of which there are numerous brands in 



HUMANIZED AND BOILED MILK. 49 

the market, the proportion of pepsin can be made accurate and 
the amount reduced from day to day as it should be, if con- 
tinued long. 

Humanized Milk. — Some infants appear to be utterly unable 
to digest diluted cow's milk, in strength sufficient to sustain 
life. Even when diluted to the proportion of one part milk to 
three parts water, they are griped, filled with flatus and are 
constantly crying with pain and discomfort. They are restless 
and suffer with diarrhea as well as with colic. They become 
lean and flabby and ultimately, if no change be made, die of 
inanition. A successful device in such cases is to put the child 
upon what is called " artificial human milk." This is prepared 
by first removing all the cream by skimming, after the milk 
has stood for a time. Then the remainder is divided into two 
equal portions. From one portion, all the casein is removed 
by rennet, i. e., converted into whey. The other portion is 
then mixed with the whey, and the whole of the cream added. 
This preparation will, therefore, contain all the lactine, all the 
cream, but only half the quantity of casein. It will thus be 
nearer in composition to human milk than cow's milk, contain- 
ing sufficient proteid and some excess of fat. But it is not 
absolutely identical with human milk, although the proportion 
of proteid is nearly the same, the curd is unchanged in nature. 
It is still, as ascertained by experiment, coarsely coagulable 
cow's milk curd, although less massive than that of undiluted 
cow's milk. The lactine is rather less, while the fat is in larger 
proportion than in human milk. This is probably an advan- 
tage, and some children who are able to digest only a limited 
amount of cow's milk casein do remarkably well on it. Dr. 
Cheadle, to whom I am indebted for this formula, states that 
humanized milk will not keep long. He says : "After a time, 
the cream separates with some curd in great clots and does not 
easily mix again. I have twice seen children dangerously ill 
from taking artificial human milk which had been sent a long 
distance and had changed in this way. If the dairy where it 
is manufactured is not within reasonable distance, have it made 
freshly at home." When thus freshly made there is no reason 
to apprehend any danger from its use. 

Boiled Milk. — The use of boiled milk in diarrhea has long 
been a practice among the laity, because experience has taught 
that when thus treated, the milk is less laxative than when 
given in its raw state. The habitual use of boiled milk has 
been objected to by the profession, under the mistaken idea 
that it is rendered less digestible by boiling. Dr. Cheadle's 
experiments have demonstrated that when milk is boiled the 
curd coagulates in smaller masses than when fresh and un- 
D. C— 4 



50 THE DISEASES OF CHILDREN. 

boiled. He says, '' Dilute acetic acid, or vinegar, added to 
boiled cow's milk which has been allowed to grow cold, no 
longer produces the massive coagula, characteristic of fresh 
cow's milk, but smaller and lighter curd masses, although still 
much larger and coarser than those of human milk." There is 
another reason why all cow's milk used in the city nursery 
should be boiled, and that is that boiling arrests decomposi- 
tion and thus puts a stop to the development of those irritant 
products that excite intestinal action. We shall see farther on 
that the dilution of milk with barley water or the juice of one 
of the other cereals promotes its digestion by mechanically 
separating the casein, so that it coagulates under the action of 
the gastric juice in minuter flocculi than that boiled even. A 
still further reason for boiling the milk for city fed infants is 
found in the fact now clearly demonstrated that milk is one of 
the commonest of disease carriers, and heating the milk to a 
temperature even of i8o° Fahr., destroys contagium or ren- 
ders it harmless. Boiling the milk entirely eradicates all dan- 
ger from this source. 

Boiling milk expels about three per cent, of its gases, and 
materially changes its odor and taste. As the boiled milk 
cools on contact with the air, a scum forms, which is the albu- 
men coagulable by heat, entangling in its meshes a certain 
amount of fat. But as cow's milk contains relatively more 
albumen (casein) and fats than human, the slight loss entailed 
by boiling is immaterial. 

Before proceeding further with the discussion let us see in 
what particulars human milk and cow's milk differ. (See table 
on opposite page.) 

It will be seen that cow's milk, as compared with human 
milk, contains less water and sugar and more butter, casein 
and salts. In order to approximate the two kinds of milk as 
nearly as possible we add for an infant during its first month 
about two parts water to one part milk and also a little sugar. 
We thus bring the caseous element of cow's milk to about 
that of human milk and the sugar is about the same. In mak- 
ing this reduction, however, we have diminished other constit- 
uents below the standard of human milk, so that a larger 
quantity of it must be given than would be required of the 
latter if we would meet the requirements of the infant's sys- 
tem. By adding raw meat juice (see page 6'S) and cream, the 
proteids and fats can be increased as needed and that in a way 
not to be objectionable even to a stomach the most feeble. 

Another, and perhaps a simpler way to reduce the amount of 
casein is to let the milk stand for an hour or so after it is de- 
livered, and then, to pour off carefully, the upper half, for a 



ELEMENTS IN VARIOUS KINDS OF MILK. 



51 



H 

£ I. 

52 





*(/; 














c 




lo -co 1 


1 


vO 


o 




o 




V Vlt) ' 


1 


■x^- 1 O 1 










CO 


° 














1 -■ 














1 


















^ 




t- ^-h 1 


1 


LO O 




< 




•« -^^ 1 


1 


b b 
o o 














1 - 1 






l^x- 


O X^ 




. 1 1 




§1. 




(N vC O CO 


LO 


n 


° 




~ '> -^ > 


ro i-i (N CO 


o 


10 1 




2 1- y 


Q " "■" 






CO 


o 




w "-^ 














£-§ 














o >* 






fO 


i> 






^i 


w 00 o o 


o 


o 


o 




U c 


n 














^ 


vO M vC t^ 


T*- 


•>; 


o 

o 






t^ vO n 


i:^ 


CO 






i-' 


uo TT O 1 


i/^ 


f 


■> o 






'•^ 5 ^ 


M T^ Lo ' 




t^ 


b 


u: 

J 


<-^" 






CO 


o 


-« „ 5 ^ 


\D «N ■<*- 


00 


o 




:S 


"^ -= ? o -3 


CN fO O 1 


^ 


(^ 


:) o 


jp 




•-■> ^rt " 


• • 




■^ 


o 


"^ 


s 


Q ? ^ N 






c 


' o 


o 






















w ^^ 


-o c >^in 


i:^ O ^ 


l-l 


<s 








3^ E.5 > 


CO Ti- o 


LO 


M 






►H t^ n 1 


CO 


>-<■ 


^ p 




« >. - 




M w c^ ' 




f 


:> b 




t^ «2 






o 


•^ o 




C V 














rt* 


"^ N 


00 vO x:^ 


Ti- 


x/ 


■) 




i< 


y t« T; 


U-. vo vO 


ro 


i> 






t-5^^ 


•I -Ml 


N 


o 


o 




'^^'^ 


S'i^^ 






a 


^ 8 




bC>' 










►H 














Sw 




■^ C^ CO 


r< 


r< 






lU 


u 


1^ oo 


O 


f< 






> 




tr> Th Tt- 1 


!>. 




O 




< 


oi 


V rOT^ ' 




00 


* 2 




< ^ 


£" 








3 


fO -^ fO 1 o 


O <N 


t/ 


o 




>2s 


hj_ 


• • 1 • 












(S ri VO 




CO 


b 




« 








00 


o 










O ^.^^.^ 






T-S '^-'-^ 








en 




ele- 
otcids 
nnen) 

or fat 
ctine . 
ne sug 


hosphoric anhjdri( 
ther constituents 
of ash 










c 
E 

w 




t- - !£ t^ "^ 




*« 

^ 












o-O 


1 



52 THE DISEASES OF CHILDREN. 

very young infant, and the upper two-thirds, for an older one, 
and to do this without disturbing the lower strata of milk into 
which the principal part of the curd has gravitated. 

By resorting to this procedure, the upper portion, which is 
the one to be given the infant, will be found to have about the 
■consistence of human milk, with the proportionate amount of 
casein and fat, and does not require the addition of water 
and but very little sugar. 

When fresh cow's milk is reduced in its casein, as just de- 
scribed, till the amount of its nitrogenous constituents is on a par 
with human milk, it is found, as we have said, to be below 
normal in its fat and sugar — the hydro-carbonates. This defect is 
remedied in a very ingenious manner by Dr. Kennedy, of New 
York, who prepares an artificial food which he calls Proteinol, 
and which can be added to the milk or other food, in quantities 
to suit any emergency. 

Proteinol is made from the entire egg (shell and all), which is 
digested in fresh lemon juice ; to this is added the clear fat from 
fresh killed beef, saccharated malt, and enough good brandy 
to keep it from undergoing change. 

Dr. George W. Winterburn's favorite food for a healthy 
child of a month old, who is not as yet affected with vomiting 
or diarrhea, but who is obliged to be put on artificial food, is 
as follows: One teaspoonful of wheat flour, boiled, baked and 
grated as described on page 56; one teaspoonful of condensed 
milk (Eagle or Anglo-Swiss) ; one-half teaspoonful of proteinol, 
and twenty-four teaspoonfuls of water. "An analysis of this," 
he says, " and an analysis of healthy, normal, average human 
milk for a child of the same age, yield exactly the same 
results." 

Sterilized Milk. — What has been said of the advantage of 
boiling milk and its increased digestibility thereby is only true 
if the milk be just brought to a boil and then removed from 
the fire — parboiled, as it were. If the boiling process be con- 
tinued for any length of time, the effect on the casein which it 
contains is precisely like that on the albumen of ^g<g. Prolonged 
boiling condenses it into a firm and indigestible coagulum 
like that of a hard-boiled ^^g. This, of course, is undesirable 
from every point of view. Even an adult stomach, unless ex- 
ceptionally gifted, finds it difficult to dispose of either egg-al- 
bumen or milk casein that has been subjected to over-boiling. 

All of the advantages which follow boiling the milk, can be 
secured by heating it to 6%'^ C. or 155° Fahr. It has been 
found by experiment that this degree of heat destroys any in- 
jurious germs or active poisons, which may have found their 
way to it, either in the cow-yard or in course of transportation. 



CEREAL FOODS AND THEIR USES. 53 

The taste of boiled milk is somewhat changed and rendered 
unpalatable, which is not the case if it be merely heated to the 
temperature above indicated. This process of heating, but not 
boiling, is called ** sterilization," and answers all the purposes 
necessary for purification and preserving without any objec- 
tionable features. A simple means of accomplishing this ob- 
ject is thus described by the United States Secretary of Agri- 
culture : 

" The vessel containing the milk, which may be the bottle 
from which it is to be used or any other suitable vessel, is placed 
inside of a larger vessel of metal, which contains the water. If 
a bottle, it is plugged with absorbent cotton if this is at hand, 
or in its absence other clean cotton will answer. A small fruit 
jar, loosely covered, may be used instead of a bottle. The re- 
quirements are simply that the interior vessel shall be raised 
about half an inch above the bottom of the other and that the 
water shall reach nearly or quite as high as the milk. The ap- 
paratus is then heated on a range or stove until the water 
reaches a temperature of 155° Fahn, when it is removed 
from the heat and kept tightly covered for half an hour. 
The milk bottles are then taken out and kept in a cool place. 
The milk may be used any time within twenty-four hours. A 
temperature of 150° maintained for half an hour is suffi- 
cient to destroy any germs likely to be present in the milk, and 
it is found in practice that raising the temperature to 155° 
and then allowing it to stand in the heated water for half 
an hour insures the proper temperature for the required time. 
The temperature should not be raised above 155°, other- 
wise the taste and quality of the milk will be impaired. 

** The simplest plan is to take a tin pail and invert a perforated 
tin pie-plate in the bottom, or have made for it a removable 
false bottom perforated with holes and having legs half an inch 
high, to allow circulation of the water. The milk bottle is set 
on this false bottom, and sufficient water is put into the pail to 
reach the level of the surface of the milk in the bottle. A hole 
may be punched in the cover of the pail, a cork inserted, and 
a chemical thermometer put through the cork, so that the bulb 
dips into the water. The temperature can thus be watched 
without removing the cover. If preferred, an ordinary dairy 
thermometer may be used and the temperature tested from 
time to time by removing the lid. This is very easily arranged, 
and is just as satisfactory as the patented apparatus sold for 
the same purpose." 

The Cereal Foods and Their Uses. — The fact that 
nature provides an animal food for the human infant, and the 



54 THE DISEASES OF CHILDREN. 

further fact that all vegetable foods contain more or less starch, 
which is not found in milk, and which does not, and cannot, 
enter into the organism as starch — these facts are on the face 
of them prohibitory, when considering their availability as a 
substitute for human milk. Physiology teaches us that before 
starch can be assimilated, it must be transformed into dextrin, 
or grape sugar. It cannot take part in the economy, until this 
change is effected. As starch, it is, when taken into the blood, 
a foreign and useless element. Physiology teaches further- 
more that in adult digestion this transformation of starch into 
grape sugar is effected by the digestive juices, with which it 
comes in contact between the mouth and the colon. The saliva 
begins the transformation and the pancreatic and the intestinal 
fluids perfect it. But the secretions of the infant are every- 
where feeble, and metabolic changes are effected with difficulty. 

It is not until the infant is a year old or more, and is in pos- 
session of eight or ten teeth, that the saliva has the power of 
effectively operating on starch, and the pancreas, which is quite 
diminutive at birth, does not reach its full proportionate size 
until second dentition is well advanced. Digestion of starchy 
substances is therefore, prior to this period, a matter of diffi- 
culty and oftentimes an impossibility. There is a great vari- 
ety of baby foods manufactured by enterprising firms, whose 
object is to present a cereal substitute for human milk, that 
shall supply the infant's system with all the requisites for full 
nutrition in a form adapted to its delicate powers of digestion. 
These foods will be discussed further along. For the present, 
suffice it to say that the grains mostly employed in their manu- 
facture are barle}/, oats and wheat, whose digestibility ranks in 
the order named. Where a domestic food is desired — that is to 
say, "home made" — a very good one is well-cooked barley 
added to boiled milk. The "prepared " or " pearled " barley, 
is the proper article to be used. A tablespoonful of this 
should first be boiled in from four to six ounces of water for 
about thirty minutes and then strained through a linen cloth. 
For very young infants the quantity of water should be six 
ounces and for older ones, say from four to six months, three 
ounces. This decoction should then be added to an equal 
quantity of boiled and skimmed cow's milk, together with a 
pinch of salt and a little sugar. If the milk has not been pre- 
viously neutralized, as heretofore directed, a few grains of bi-car- 
bonate of soda should be added. 

This preparation should be given at a temperature of 85° or 
90° Fahr., and for infants under six months old should be served 
through a nursing bottle with a black or brown rubber tip. 
The white rubber tips are unfit for use on account of the chem- 



CEREAL FOODS AND THEIR USES. 55 

icals used in bleaching them. The best nursing bottle is a 
common flat glass bottle with just enough rim around the neck 
to hold the tip securely. Care should be taken to select a tip 
with perforations large enough to permit a free flow on suction, 
but not large enough for any considerable flow otherwise. 

To insure perfect cleanliness, two bottles and corresponding 
tips should be provided, and the ones not in use, should be 
kept in a moderately strong solution of bicarbonate of soda — 
a teaspoonful to a cup of water. No patent nursing bottle, 
Avith a glass or ivory stem extending into its interior, should be 
employed, as it cannot be kept clean. 

In some cases oatmeal may be beneficially substituted for 
barley in the above decoctions, especially where there is a de- 
cided tendency to constipation. 

It will be found that barley water is better borne by infants 
with a delicate stomach, while oatmeal is a slightly heartier 
food and requires a stronger digestion to assimilate it. It must 
be understood that the real object of adding any of the cereals 
to milk is not so much to increase its nutritive properties nor 
to add anything to its tissue-making elements, but to increase 
the digestibility of the milk curd. It cannot be too often re- 
peated that the great trouble which infants encounter in digest- 
ing cow's milk is due to the firmness and coarseness of its 
coagula. Whatever combines with these caseous masses and 
renders them finer promotes their digestion. Dr. Jacobi speaks 
in very high terms of gum arabic for this purpose. He says: 
*' Looking for a substance, which, while fulfilling this object, is 
absolutely indifferent, from a chemical and physiological point 
of view, it is gum arabic. Its decoction, therefore, as it is not 
influenced by the digestive liquids and is not absorbed, acts 
mechanically only. If I meant to write a eulogy on gum arabic, 
I should add, that its unpretending and unaggressive nature 
renders it particularly fit for an addition to children's food, 
when, in more advanced years also, their irritated intestines re- 
quire a soothing addition to the necessary nutriment. With 
the casein of this mixture the gastric juice will get into very 
slow contact indeed, thus producing a looser, because a more 
gradual and interrupted coagulation, on which the digestive 
liquids and the peristaltic motion of the stomach have a better 
opportunity to exert their influence." He directs that a small 
quantity of this thin and transparent mucilage be added to 
boiled cow's milk, which has been skimmed and to which has 
been, or should be, added the proper quantity of sugar, salt and 
soda. We have had no experience with this ourselves, but 
the authority of Dr. Jacobi is ample evidence of its utility. 

Instead of gum arabic, Messrs. Meigs and Pepper use gelatin 



56 THE DISEASES OF CHILDREN. 

by preference, and their formula is indorsed by other high au- 
thorities. We have ourselves found it very serviceable in cases 
where other foods have failed and we can surely give it credit 
for saving one infant's life where previously we had tried nearly 
every other preparation without success. 

The length of the formula, and the necessity of extreme 
accuracy in measuring its component parts, renders it objection- 
able, for few mothers or nurses are willing to go to the requi- 
site trouble or are too careless to make its preparation success- 
ful. The author's formula is as follows : Dissolve a small 
quantity of prepared gelatin or Russian isinglass in water to 
which is added milk, cream and a little arrowroot, or any other 
farinaceous substance that may be preferred. A scruple of the 
gelatin (or a piece two inches square of the flat cake in which 
it is sold) is soaked for a short time in cold water, and then 
boiled in half a pint of water until it dissolves — about ten or 
fifteen minutes. To this is added, with constant stirring, and 
just at the termination of boiling, the milk and arrowroot, the 
latter being previously mixed into a paste, with a little cold 
water. After the addition of the milk and arrowroot, and just 
before the removal from the fire, the cream is poured in, and a 
moderate quantity of loaf sugar added. The proportions of 
milk, cream and arrowroot, must depend on the age and digest- 
ive power of the child. For a healthy infant within the month, 
we usually direct from three to four ounces of milk, half an 
ounce to an ounce of cream, and a teaspoonful of arrowroot to 
a half pint of water. For older children, the quantity of milk 
and cream should be gradually increased to a half or two-thirds 
milk, and from one to two ounces of cream. We seldom in- 
crease the quantity of gelatin or arrowroot. 

This food is especially recommended for infants suffering 
with diarrhea, colic and vomiting, and who cannot retain milk 
and water or cream and water. 

Wheat flour may be used for this same purpose, and, when 
properly prepared, makes an admirable baby food, as we have 
often demonstrated in our personal experience. A pound or 
two of ordinary wheat flour is placed in a muslin bag, and 
boiled for four or five hours in water sufficient to cover it — the 
longer the better; it should then, without removing the bag, 
and after being drained dry, be placed in an oven and baked 
into a hard lump. When thoroughly baked through, the mus- 
lin covering should be removed and the ball grated as wanted 
into flour. This flour may now be added to the boiled milk in 
quantities according to the age of the infant. 

Some years ago. Dr. Churchill, of Dublin, suggested a food 
made out of stale bread, which he called bread jelly, and which 



COMMERCIAL BABY FOODS. 57 

is admirably adapted to educate a child's stomach up to a point 
where it can digest cow's milk. He prefers bread made out of 
*' seconds " flour, as this is richer in proteid and phosphates 
than that made from the finer flours. A thick slice of this 
bread — about four ounces — two or three days old, is placed in 
a basin of cold water and allowed to soak for six or eight 
hours. It is then taken out, and all the water squeezed out of 
it. The object of this first soaking is to clear away the lactic 
acid formed in fermentation, and all other deleterious matters. 
The pulp is then placed in a pint of fresh water, and gently 
boiled for an hour and a half. The object of this prolonged 
boiling is to thoroughly break up the starch corpuscles, and to 
promote the change of starch into dextrin and grape sugar. 
The thick gruel thus made is strained, rubbed through a fine 
hair sieve, and allowed to grow cold, when it forms a fine, 
smooth, jelly-like mass. This should be prepared freshly each 
night and morning, for it will not keep long. Enough of the 
jelly is then mixed with warm water, previously boiled, to 
make a food of the consistence of thin cream, so as to pass 
readily through a nursing bottle. This means about one full 
tablespoonful to eight ounces of water. A little white sugar 
may be added. This is very weak food and wanting in almost 
every element of full nutrition. It is, however, easily brought 
up to a high nutritive standard by adding some animal element, 
such as boiled milk, if milk is tolerated, and if not, by adding 
instead raw-meat juice and cream, the latter to supply its nota- 
ble lack of fat. There may be added to each bottle as needed 
in the proportion of four to six teaspoonfuls of raw-meat juice 
and two teaspoonfuls of cream. Care should be taken that 
everything entering into this concoction should be fresh, or 
serious trouble may follow. Raw meat is especially liable to 
undergo decomposition. 

The Commercial Baby Foods. — The care necessary to 
properly prepare a domestic infantile food, and the ignorance 
and inexperience of both mothers and nurses are so widespread, 
that numerous efforts have been made to meet the wants of uni- 
versal babyhood by manufacturing these foods on a large scale 
and placing them on a stable and satisfactory commercial basis. 
Many physicians object to these preparations on various 
grounds, and insist that the home product is every way prefer- 
able. We cannot agree with this idea. Because an article of 
wide consumption is made a matter of merchandise, it certainly 
does not follow that its preparation is lacking in uniformity, or 
that less care is taken in the making than otherwise. On the 
other hand, the manufacturers have the strongest incentives in 



58 



THE DISEASES OF CHILDREN. 



the world to produce not only the best food that science can 
devise, but to maintain the integrity of its standard of excel- 
lence. They are necessarily provided with machinery and 
appliances for its manufacture, and experts to superintend 
every step of its evolution. They have experienced buyers 
to select the materials which enter into its composition, and 
means at their command to get the best the markets afford. 
The rivalry between the different foods for supremacy, is 
alone sufficient to insure uniformity of grade and perfection 
of output. 

Their attention is not diverted every few moments from the 
work in hand to something entirely foreign. They are not dis- 
tracted at a critical moment by a crying baby, or wearied by 
night-vigils into forgetfulness of formula. It is their sole busi- 
ness to bring about the best results, and if their advertisements 
are sometimes exaggerated in statement, it is the business and 
the duty of the physician to inform himself of the true merits 
of the case and to act accordingly. It is unreasonable to sup- 
pose that all of the patent foods are of equal value, and equally 
absurd to regard them as devoid of merit or a fraud upon the 
public. 

For convenience of comparison and in order to form an intel- 
ligent idea of the relative nutritive value of these foods. Pro- 
fessor Leeds, of Stevens Institute, has made a classified analysis 
of the principal ones used in this country, dividing them into 
three classes as follows : 

Farinaceous foods, viz.. Imperial Granum, Ridge's Food and 
various " wheat foods " and '' barley foods ;" the so-called 
Liebig foods, viz., Mellin's, Horlick's and Hawley's ; milk 
foods, viz., Nestle's, Gerber's and the condensed milks. 

Farinaceous Foods. 





1. 

Blair's 
wheat 
food. 


2. 

Hubbell's 
wheat 
food. 


3. 

Imperial 
granum. 


4. 

Ridge's 

food. 


5. 
"A. B.C." 

Cereal 
milk. 


6. 
Robin- 
son's pat. 
barley. 


Water 


985 

I 75 
1-71 
64 80 
13 69 
7-16 
294 
I 06 


7-78 
041 

4 87 
67 60 
1429 

lo" 13 

Undet'r'd 
1 00 


5 "49 
I 01 

Trace. 

Trace. 

78 93 
356 

1051 
oi;o 
I 16 


923 
063 

2 40 

2-20 

77-96 

5"i9 

924 

60 


933 

lOI 

4 60 

15 '40 
58 42 
20 00 
II 08 
I 16 


10' 10 


Fat 


097 


Orape sugar ... 


3 oS 


Cane sugar .... 


090 


Starch 


77 76 


Soluble carbohydrates 

Albuminoids 

Gum, cellulose, etc. . . 
Ash 


411 
5'i3 
I 93 
I 93 







COMMERCIAL BABT FOODS. 
LiEBiG Foods. 



59 





Mellin's. 


Ilawley 's 


Keas- 

bev and 

Matti- 

son"'s. 


Savory 

and 

Moore's. 


Baby sup 
No. 1. 

5-54 

1-28 

2 "20 

II 70 

61 99 
14-35 

9-75 

709 

Undet'r'd 


Baby sup 
No. 2. 


Water 


15 00 

0-15 

44-69 

3 5^ 
None. 

85 44 
5-95 

I 89 


6 60 
61 

40-57 
344 

1097 

76 54 

538 

1-50 


27-95 

None. 
36-75 
7-58 
None. 
71-50 
None. 

0-93 


8-34 

40 
2041 

908 
36 36 
44-83 

963 

044 

089 


11-48 
062 


Fat 


Grape sugar 

Cane sugar 


2-44 
2 48 

51-95 

22 79 

792 

5'24 
I '59 


Starch 


Soluble carbohydrates 

Albuminoids 

Gum, cellulose, etc. . 
Ash 



Milk Foods. 





Nestle's 


Ang-lo- 
Swiss. 


Gerber's 


American- 
Swiss. 


Water 


4-72 
I 91 
692 

32-93 
40" 10 

44 -88 
8-23 
I 59 


6 "54 

272 

23-29 
21 40 

34-55 

46-43 

1026 

I 20 


6-78 
2-21 
606 

30-50 
3848 

44 76 
9 56 

I-2I 


^■68 
681 


Fat 


Grape sugar and milk sugar . . . 
Cane sugar. 


5-78 
36 43 
30-85 
45-35 
10 54 

I ■ 21 


Starch .... 


Soluble carbohydrates 

Albuminoids 


Ash 







It will be seen at a glance that all of the farinaceous foods, 
of which Imperial Granum may be taken as the type, and the 
"■ milk foods," of which Nestle's is the best representative, the 
starch is unchanged, and this fact renders all of this class of foods 
unfit for very young infants or those with feeble powers of di- 
gestion. For infants of strong digestive powers, however, and 
for those in whom age has developed the peptic juices to an 
adequate extent, these foods are valuable and reasonably reli- 
able. The farinaceous foods are notably lacking in fats, but 
are sufficiently rich in albuminoids. The want of fat and also 
of sugar should be corrected in administering these foods. 

The other class of foods is much better adapted to very 
young infants, for the reason that in the preparation of them 
the starch which they contain is to a greater or less extent con- 
verted into dextrin or maltose, and their digestibility thereby 
greatly facilitated. 

The maltose or grape sugar is the ultimate end which all 



60 THE DISEASES OF CHILDREN. . 

starch must reach before it can be assimilated, and it is this 
transformation of starch into sugar that most troubles the 
young infant, in its attempt to digest artificial foods. This 
food was suggested by Liebig many years ago, and consists 
mainly in mixing malted barley meal with wheaten flour, and 
adding an alkali, either potash or soda. Under a certain amount 
of heat the diastase of the malt acts on the wheaten flour and 
changes it into dextrin, then into maltose and then into grape 
sugar. This is in strict accord with physiological requirements. 
The process of converting the starch into grape sugar artificially 
is not weakening or demoralizing to the infant's stomach, since 
the diastase of the malt only does for the child what the mother 
herself does, viz.: converts starches and sugars into lactin be- 
fore they are supplied to the child in the mother's milk. 

The best representative of this class of foods is that known 
as Mellin's, and this we have used in our practice for some 
twenty years with unabated satisfaction. Mixed with a due 
proportion of boiled (sterilized) cow's milk this food has met 
the requirements of more infants than any other food with 
which we are acquainted. 

Mellin's food possesses one great advantage over other arti- 
ficial food preparations. By adding it to milk in varying pro- 
portions the alvine evacuations can generally be regulated with 
great nicety. When the bowels are too loose more milk should be 
added, and when there is a tendency to constipation this can be 
remedied by lessening the quantity of milk and giving the food 
nearly or quite clear. 

Meat Preparations.— There seems to be a great diversity 
of opinion upon the nutritive properties of the various patent 
meat extracts, beef essences and juices, with which our mar- 
kets are flooded. The manufacturers and vendors of these prod- 
ucts are more actuated by a desire to utilize in a profitable 
way the waste materials of the stock yards than to meet a liv- 
ing demand in a scientific way. The weight of authority and 
of clinical experience seems to be against them. The action 
of heat to which they are subjected in course of preparation 
coagulates the albumen in which they are none too rich, and 
furnishes too large an amount of extractives of low nutritive 
value. Beef tea, however made, is a very poor food for chil- 
dren and should never, for any great length of time, be de- 
pended upon alone. Its laxative character prohibits it in 
diarrhea. The same may be said of veal, and chicken broth. 

Raw-meat juice is, however, of great value, and may be used 
as a substitute for the casein of cow's milk. In sickness, when 
but little food is tolerated by the stomach, raw-meat juice caa 



GAVAGE (FORCED FEEDING). 61 

be given in small quantities with great benefit. The best way to 
prepare this is to get a pound of the round of beef and have it 
ground through a machine. After being heated over a quick 
fire, the juice should be squeezed out with a strongly made 
lemon squeezer. A good juicy piece of beef ought to yield 
nearly an ounce and a half of juice to the pound of meat. 
Another method of securing the same result is to place a thick 
piece of raw beef in a proper receptacle over a hot fire for a 
few moments and then press out the juice with a potato masher. 
The amount of juice yielded in this way is very much less than 
by the previous method. The red, platter gravy, which ex- 
udes when a piece of roast beef is cut, can also be made avail- 
able. The juice of raw or nearly raw meat (beef), however it 
may be secured, can be added to milk or to cream, and is a 
very valuable addition thereto. There is nothing more digest- 
ible and nothing more nutritive. 

Gavage (Forced Feeding). — As a means of controlling 
obstinate vomiting in the acute, wasting diseases of infancy 
and childhood, Dr. L. Emmett Holt has recently suggested the 
employment of gavage. The process of using is simple and 
worthy of consideration in cases where ordinary feeding has 
proven unsatisfactory. Dr. Holt says : * 

*' During the past two years gavage has been in daily use in 
three institutions with which I am connected, the Babies' Hos- 
pital, the Nursery and Child's Hospital, and the New York 
Infant Asylum. Our experience has now extended to obser- 
vations upon upward of four hundred cases, in most of which 
gavage has been repeated many times. It has been tried in 
almost every variety of acute disease in infants and small chil- 
dren, and has won its place as one of the most valuable of our 
therapeutic measures at this time of life. 

" The technique of gavage is very simple. The ordinary ap- 
paratus used for stomach-washing is all that is required, viz., a 
funnel, eighteen inches of rubber tubing, a soft rubber catheter, 
and a few inches of glass tubing for connection. The catheter 
should have a double eye. No. 14, American scale, is the best 
size for infants under six months, and about No. 17 for older 
children. A four-ounce funnel is large enough for infants, while 
for older children it is an advantage to use one holding six or 
eight ounces. The child is placed flat upon the back in its crib, 
and the head steadied by an assistant. The tongue is depressed 
with the left forefinger, and the catheter, previously oiled, is 
pushed rapidly down the pharynx until nine or ten inches have 



New York Medical Record, April 2S, 1S94. 



62 THE DISEASES OF CHILDREN. 

passed the lips. The funnel is now raised high in the air for a 
few moments to allow gas from the stomach to escape. The 
food is poured into the funnel and rapidly runs into the stom- 
ach. As the last of the food leaves the funnel the catheter is 
tightly pinched and quickly withdrawn. This last step is an 
important one, in order to prevent trickling of food in the 
pharynx, which may provoke vomiting. Sometimes the food 
remains in the funnel, and will not run into the stomach. This 
is not ordinarily from blocking the eye of the catheter by mu- 
cus, but from gas in the tube. In a few moments this gener- 
ally rises to the surface of the liquid, and then the food flows 
readily. If regurgitation of the food takes place, it is generally 
immediately after withdrawing the tube. In many cases it may 
be prevented by allowing the gas to escape from the stomach 
before putting the food in, and in others by holding the jaws 
separated for a few moments after the catheter has been with- 
drawn. 

** In young infants no gag is required, but in older children one 
is quite necessary, since otherwise they may bite the catheter 
in two. Where a gag is needed the ordinary one accompany- 
ing intubation sets will answer the purpose. Two assistants 
are usually required to feed an older child. It is important 
that the child should be held flat upon its back. 

*' The time consumed in feeding by gavage is from ten to thirty 
seconds. In infants this is very easily done. In the institu- 
tions referred to all the nurses have been taught to do it, and 
they learn with very little experience to do it very quickly. 

" The uses of gavage may be briefly stated as follows : 

"I. In premature infants its value has been well established 
on the continent of Europe, in connection with the use of the 
incubator. As yet we have had but little experience with it in 
this country. 

"2. It is useful in controlling persistent vomiting in very young 
infants, where the vomiting occurs partly from habit and partly 
from exaggerated pharyngeal reflex. Dr. Kerley's published 
paper established this point conclusively, and subsequent ex- 
perience has confirmed his observations. Dr. R. B. Kimball, 
attending physician to the Summer Branch of the Babies' Hos- 
pital, is soon to publish a large number of cases treated in the 
summer of 1893, also confirmatory of this point. I will not 
enlarge upon it. 

'^3. In acute diseases, where for any reason children refuse all 
food, or struggle violently against everything that is offered 
them. In very many cases of severe illness in children from 
two to five years of age, the point is reached, after four or five 
days have passed, when the child absolutely refuses to take any- 



GAVAGE {FORCED FEEDING). 63 

thing, and nothing is gotten down excepting by holding the 
nose. This is, to my mind, one of the most promising fields 
for the application of gavage. In very severe cases of scarlet 
fever, diphtheria, broncho-pneumonia, typhoid, and empyema 
just this necessity is felt. 

"4. In serious brain disease, where the patient cannot be fed 
by ordinary means. This may occur in tubercular meningitis, 
chronic meningitis, and in many other diseases where delirium 
or coma is a symptom. Life is not only prolonged, but exist- 
ence made more tolerable, and the patient is much more easily 
cared for by the attendants. 

*'A few illustrative cases will serve as types of many : A child, 
aged three, with chronic meningitis, was fed for six weeks by 
gavage ; by no other means could anything be gotten down 
excepting by the expenditure of a great deal of time, strug- 
gling, and holding the nose. 

''A child, aged two, with empyema and very marked asthenic 
symptoms, after two weeks' illness absolutely refused every- 
thing in the way of nourishment, and was in danger of dying 
from inanition. For two weeks all food was given by gavage, 
at the end of which time the child was able and willing to drink 
its milk from a cup, and take stimulants without difficulty. 

''A private patient, aged twenty months, with double pneu- 
monia and very marked prostration, had reached the point, by 
the tenth day, when almost nothing could be done in the way 
of nutrition. After gavage for two days the temperature grad- 
ually fell, the patient was able to take food naturally, and 
made an excellent recovery. 

** In a recent case of tubercular meningitis seen in consultation 
in private practice — the case was hopeless for five days before 
death — all the food was given by gavage. After the case 
closed, the attending physician said, ' You have no idea what 
a comfort the gavage was to the family.' This was especially 
noticeable after the struggles to give food which had preceded 
its use. 

"A recent case of diphtheria in private practice in a little girl 
aged five affords a striking illustration of the benefit of this 
means of treatment. The patient was delirious, profoundly 
septic, temperature 105° Fahr. and over for a week; pharynx, 
tonsils, uvula, palate, aud part of the mucous membrane of the 
mouth covered by pseudo-membrane. In the words of Dr. 
O'Dwyer, who saw the case, ' the symptoms were about as bad as 
they could be.' After the fifth day, to give either food or stimu- 
lants by ordinary means was absolutely impossible. She was be- 
ing worn out with the constant teasing and forcing. Even at the 
risk of heart failure three nurses held her while I employed gav- 



64 THE DISEASES OF CHILDREN. 

age for the first time. Not more than three ounces of food had 
been gotten down in the course of the previous twelve hours. 
Four ounces of food and one ounce of brandy with digitalis 
were given without difficulty, and with but little more disturb- 
ance than was necessary to make the child swallow a table- 
spoonful. From this time on gavage was practiced regularly 
every six hours ; the amount of food was gradually increased 
until eight ounces at a time were given at once. This was kept 
up for a week ; not once was the food regurgitated, and the 
case made a complete recovery. In my own opinion the life 
of the patient was saved by this means. 

" To cite further cases is unnecessary; enough has already been 
said to show that gavage is easy, simple, and free from danger, 
and a very great resource in these very difficult cases. 

** In the adult when food is refused by the stomach we may 
have recourse to the rectal alimentation ; but in little children 
this is extremely unsatisfactory, and in most cases is an entire 
failure. As compared with holding the nose, and forcing the 
child to swallow, anyone who has seen the two things done will, 
I think, have little difficulty in deciding which is easier. 

" In most of the cases to which I have referred the food given 
has been completely peptonized milk, diluted according to the 
age of the child ; but for infants our hospital milk and cream 
mixture in proportions suitable to the child's age. Stimulants, 
medicine, everything that is to be given may be poured in at 
once. 

*' In older children, where six or eight ounces at a time are 
given, gavage need not be repeated more than once in five or six 
hours. In infants the intervals should be one hour longer than 
the customary interval of feeding. 

" Stomach washing is required in conjunction with gavage in 
most cases in infants ; once at least every day the stomach 
should be washed before feeding. 

" In conclusion I can only say to those who are unfamiliar 
with this therapeutic measure that a careful trial will convince 
anyone of its very great value." 

RECAPITULATION. 

1. Human milk is the only natural food for human infants, 
all other foods being " alien," '* artificial " — mere substitutes. 

2. The only reliable test for human milk, as also for all sub- 
stitutes, is the practical one of experience. 

3. Cow's milk is practically the best substitute for breast- 
milk, but should never be given to young infants in its raw 
state — always boiled, parboiled or "sterilized." 



RECAPITULATION. 65 

4. The cereal foods should never be given for any considera- 
ble length of time, except in combination with milk. 

5. The real object of adding cereals to milk is not to add to 
its nutritive properties, but to increase its digestibility. 

6. This they accomplish by prolonging the digestive act and 
preventing too rapid coagulation into large masses of coarse 
curd. 

7. The cereals best adapted for infant diet are barley, oats 
and wheat. 

8. When prepared by domestic processes, they should be 
thoroughly cooked until the starch they contain is more or 
less transformed into maltose. 

9. Gum arabic, gelatine, or any other bland and unirritating 
substance may be added to milk with the same end in view. 

10. All artificial infant foods should be given at the body 
temperature, 100° Fahr., and through a clean nursing bottle. 

11. Regularity in feeding is every way essential. 

12. As soon as an infant has half a dozen teeth its diet 
should be liberalized, i. e., varied so as to stimulate the devel- 
opment of the peptic glands and increase the digestive powers. 

D. C— 5 



CHAPTER VI. 

NURSERY HINTS. 

Sanitary science, which has done so much for the mother, 
has done but Httle, if anything, for the baby. Antiseptic mid- 
wifery has rid the lying-in room of much of its sufferings and 
most of its dangers. But the nursery is still the home of diar- 
rhea, colic, and other preventable diseases, which are or should 
be a reproach to scientific medicine. Ophthalmia neonatorum 
will never be found in a well-ordered nursery, where proper 
cleanliness is observed ; and all forms of stomatitis are directly 
traceable to a lack of care in the management of the infant's 
diet. 

A babe which is properly bathed, and whose skin is kept in 
a healthful and natural condition, should never have eczema. 
There will be space here for only a few hints regarding the 
baby's home and its sanitary treatment. If pages were written 
until they were multiplied into chapters, and these chapters 
into books, the gist of the whole thing could be summed up in 
two words — perfect cleanliness. 

In the ideal nursery every necessary and portable utensil 
should be duplicated, so that when one is in use, another is being 
sterilized or rendered aseptic by approved methods. This ap- 
plies to the teaspoon, the nursing bottle, and the crockery. 
The baby's linen and the diapers should receive special atten- 
tion, and be washed and dried with more than ordinary care. 
When possible, the antiseptic properties of sunshine should be 
utilized to its fullest extent in this connection. The infantile 
*' boss of the home," should not only have the freshest of milk, 
and the best the house affords in the way of dietetics, but 
scrupulous, excessive care should be exercised to exclude from 
his surroundings everything calculated to irritate the hyper- 
sensitive skin, or poison the atmosphere surrounding his sensi- 
tive and susceptible organism. If half the care, forethought and 
expense were given to the rearing of human beings that is usu- 
ally deemed necessary in the breeding and rearing of stock, the 
mortality of infants under five years of age would soon drop 
below the humiliating figure of fifty per cent. 

The only two points necessary to dwell upon here relate 
to washing and dressing the infant. Many mothers make 
(66) 



BABT'S FIRS 7' TOILET— GERTRUDE SUIT. 



67 



hard work of both proceedings, because they do not know 
the better way. 

The Baby's First Toilet.— A new-born baby is covered 
with four substances, — amniotic fluid, mucus, blood, and ver- 
nix caseosa. The first three of these are easily wiped off 
when the baby is just born, the last can best be softened and 
removed by warm sweet oil. So immediately rub him clean of 
the first three substances, and oil him from head to foot with 
the warm sweet oil, being careful to rub with the palmar sur- 
face of the hand and fingers, in the 
groins, armpits, and dorsum where 
this white wax is most abundant. 
Wiping this oil and vernix off 
leaves the skin as soft as velvet. 

Dress the navel with absorbent 
cotton, instead of burnt linen, as 
was the old custom, adjusting a 
plain, unhemmed band about five 
inches wide just tight enough to 
retain the navel dressing and still 
be entirely comfortable to the 
baby. 

After adjusting the diaper, the 
dress should receive attention. The 
evolution of a more humane and 
physiological dress for the baby 
has created much interest. To- 
day the Gertrude baby dress is the 
most comfortable and healthy, as 
well as the most admired infant 
costume extant. It has received 
the encomiums of many distin- 
guished physicians in this country 
and abroad, as well as the kindly 
mention of thousands of mothers. Said a happy mother in a let- 
ter to the author, " I have never had the pleasure of seeing you, 
but my baby has been in the Gertrude suit for eight months 
and if you have done nothing else in your life but give this 
suit to the babies, you may still count your life a success." 

The Gertrude Suit."^ — The undergarment (see Fig. i) is 
made of some warm, soft, fleecy material, and reaches from the 
neck to the wrists, and to eight or ten inches below the feet. 

* Patterns for the Gertrude Suit (five in a set for $1.00) can be had of Gross & Del- 
bridge, 4S Madison street, Chicago. 




r.^. I 



68 



THE DISEASES OF CHILDREN. 



The hems and seams are turned upon the outside so that it is 
soft and fleecy within. 

The second garment (see Fig. 2) is of the same shape as the 
other, with the same princess curves, but without sleeves. It 
is an inch larger than the other one, so as to fit over it comfort- 
ably. The armholes are pinked or scalloped, but not bound, 
so as to be easy and comfortable to the baby. This middle 
garment is made of baby flannel. 

The dress (see Fig. 3) is of any material you like, warmer in 





FI6.3. 



winter and cooler in summer, but of the same shape, only 
slightly larger so as to fit comfortably over the others. This 
may be made as simple or as elaborate as you please. 

These three garments are put together before dressing, — 
body within body, and sleeve within sleeve. After diapering 
the baby, the suit is put over its head as one garment, the 
little bare arms going into the sleeves without friction or fret- 
ting. Tie and button behind, and the baby is dressed with one 
pin instead of fifteen. Each garment has a draw-string tie at 
the neck to make it fit a baby of any size. These tie strings 
should be of different colors, so as not to mismatch in tying. 



THE DAILY BATH. 69 

The back of each garment is opened downwards about five or 
six inches, and in the middle of this space is one button, so 
that each garment has a tie and one button only. 

Never put two buttons on the baby's dress where one will 
serve. Reduce the drudgery of motherhood at every point, 
remembering the two governing principles in all this work for 
our babies and their mothers, — namely, health to the baby and 
ease for the mother. 

The nightgown, of some soft and warm material, is made just 
like the undergarment in the suit (see Fig. i). This and the 
diaper is all the baby wears at night. 

The diapers are of canton flannel and are of two sizes, the 
hems being upon the outside and turned down but once. The 
larger one is eighteen inches square and the smaller one ten 
inches square. This smaller one is so adjusted upon the larger, 
that when soiled, we have a small diaper to wash instead of a 
large one. 

The Daily Bath. — Some excellent physicians to-day are 
sharply criticising the daily bath, and charging it with many of 
the ills of infant life. It is undoubtedly true that the old bath, 
so tedious and fatiguing to the mother and so unpleasant and 
exhausting to the child is a species of refined cruelty that 
should be relegated to the things of the past. I am aware that 
it is easy to find fault with old customs, and not always easy 
to give the world something better ; but if the bath is properly 
given, we have something eminently healthful and easy to put 
in practice. I would give young mothers specific directions in 
this matter. 

Make all preparations for the bath complete before touching 
the baby. Place upon the carpet, a little in front of the fire, 
a rubber sheet a yard or more square. Upon this an infant's 
bath tub, half full of water at the proper temperature, say 92 
to 98 degrees, but the mother's instinct will guide her as to 
what will please the baby in this matter. A soft sponge or 
wash cloth is thrown in the water. ** What soap shall I use ? " 
Not any for the first two years. 

The lye which is the bottom fact in all soap without excep- 
tion is unkind to a young baby's skin, and it is most unkind 
where that skin is the thinnest, behind the ears, in the fat folds 
of the neck, under the arm-pits, and about the privates. Since 
abandoning the use of soap, excoriations are a thing of the past. 
You can make a baby perfectly clean with pure water and the 
skin will be as soft as velvet. There is an oily, sebaceous nour- 
ishment to the skin from within, rendering it soft, pliable and 
beautiful, and this the lye of the soap seeks out, leaving the 



70 THE DISEASES OF CHILDREN. 

skin dry and harsh. Pure water will remove the dirt, without 
disturbing this natural dressing. 

Now place two chairs between the bath tub and the fire. 
Over one of these place the Gertrude suit all nicely adjusted. 
Over this a soft towel. Over the other chair place a receiving 
blanket (a woolen blanket with a canton flannel one inside), 
these two while getting thoroughly warm will keep the heat 
from you while giving the bath. Fold the diaper diamond 
shaped, put an old rag in it, roll it, stick a pin in it, place it 
around behind the chairs on the warm hearth. 

Now, having everything ready, take the baby from the crib, 
remove the night-gown and diaper, for that is all the baby 
wears at night. The bandage, the shirt, the pinning-blanket, 
the skirt and double-gown are a bit of refined cruelty in baby's 
preparation for sleep. You could not sleep with all this cum- 
bersome clothing. Do not ask your baby to. Let it have the 
same delightful freedom which you enjoy when resting. 

With the naked baby in your hands, kneel upon the right 
knee by the bathtub, lay the baby all over in the water, save 
the face, the head resting for safety in the palm of your left 
hand. With the free right hand take the sponge, and begin al- 
ways at the top of the head. Bathe the eyes, ears, nose, mouth 
and neck, the chest, the armpits, and the privates thoroughly 
and so down to the feet. Now turn the baby over, his chest 
resting upon the palm of your left hand, holding it high enough 
to keep the nose and mouth out of water. Then with the free 
right hand take the sponge, and again begin at the top of the 
head, bathing successively the back of the head, the neck, the 
shoulders, across the kidneys, and so down to the feet. In this 
way you know whereto begin and know when you get through. 
You have bathed the little one thoroughly from head to foot 
without repeating yourself or leaving any parts untouched. 

Set the baby up in the end of the bath tub and draw on to 
your lap from the second chair, that now warm receiving blanket, 
place the baby in it, wrapping it closely to the neck, tucking 
some portions of the inside blanket under each arm and be- 
tween the limbs. From the first chair take the warm, soft towel 
and wipe the face, head, and neck, take the brush and part the 
hair, thus making the toilet complete to the neck, before ex- 
posing the body. Now set the baby up on your lap, and let 
the blanket fall nearly to the hips, and lo ! baby is all dry ; but 
a little brisk rubbing with a towel or the palm of the hand, 
will make a bright glow upon the skin and rouse capillary cir- 
culation. 

Now take the Gertrude suit all warm and comforting from 
the first chair, place it all over baby's head at once, put the 



SLEEP; WHAT IT MEANS TO BABY. 71 

arms in, tie and button behind, and the baby is dressed to the 
hips and without a pin. Lay the httle one down upon your 
lap as if to diaper it, and now for the first time expose the bot- 
tom and limbs, and they too are all dry, but apply a little brisk 
rubbing as before, then reach around the chair and get that 
warm diaper on the hearth and put it on and your task is done 
— beautifully and healthfully done. You have bathed and 
dressed your baby easily in seven minutes instead of forty — 
the time which the average nurse and mother consume in this 
task. 

What are some of the advantages of this over the old bath ? 
Let us see. In the first place you have saved each day a half- 
hour of exhausting work, making one hundred and eighty-two 
and one-half hours saved in the year, simply by learning to do 
one motherly duty right instead of wrong. Secondly, it means 
that you have changed a trying and exhausting duty into a 
mere frolic, highly pleasurable to both you and the baby. 
Thirdly, this bath has a wonderfully quieting influence. Often 
when called to children in convulsions, I have placed them in a 
quite warm bath, when they would return to consciousness al- 
most immediately. Now, if this warm full bath is so soothing 
as to take a baby out of a convulsion, the most nervous state 
in which it is ever found, it must be very tranquilizing. And 
so we find it. This bath makes a baby happy, full of smiles, 
dimples and fun all day long, while the old bath and dressing 
has a tendency to make him irritable. 

When shall we bathe the baby ? Daily, and always on an 
empty stomach. A good time is just before the second nurs- 
ing. When w^e remember how essential to high health is a soft, 
velvety skin ; how that every pore is a minute sewer, and that 
the skin itself is a displayed lung, helping to oxygenate the 
blood, we shall appreciate the value of a daily bath. 

SLEEP ; WHAT IT MEANS TO BABY, AND HOW TO SECURE IT. 

One of the great specialists of the land regards sleep as a 
conservator of high health, and says it will do much, both to 
prevent and cure nervous diseases ; that if he could get into 
our great insane asylums, and, by any fair means, induce the 
inmates to have eight hours of sweet sleep at night and one 
hour during the day, he would soon send the bulk of them 
home cured. So much does he think of sleep as a preventive 
and panacea for nervous diseases. I quote him, not because 
he is peculiar in his views, but because he voices the best 
thought of the best men in the profession. 

A large proportion of the diseases of infancy are nervous 



72 THE DISEASES OF CHILDREN. 

diseases. Look at all the cramps and convulsions so common 
in early life ; look at whooping-cough, meningitis, basilar and 
cerebro-spinal ; think of the crying spells, the insomnia, the 
starting from sleep at the slightest noises. 

If the diseases of infant life are nervous diseases, and sleep 
will prevent and cure them, how important it is to sleep the 
baby abundantly. '* But," says the young mother, '' the more 
baby sleeps, the better I like it ; you won't catch me waking 
baby when she is sleeping sweetly." That is all right as far as 
it goes, but she must learn to conserve baby's habits of sleep. 

How ? First, remember the necessary conditions of rest the 
world over, namely, darkness and quiet. The lamp burning all 
night spoils the first condition, and the frequent hovering over 
the little one, defeats the second. 

Secondly, have regular hours for sleep. When six o'clock 
comes, the good wife undresses the baby as naked as it was 
born, rubs it with a Turkish crash towel, puts on a diaper and 
nightgown, nurses it, and puts it to bed. This is a finality; it 
does not get up in five minutes, or one hour, or two hours. It 
never has been taken up, and does not know that such a thing 
is possible, so it never cries to get up. 

After a second nursing each day it goes to bed for a two- 
and-a-half hours' nap. How do you get your baby to sleep ? 
Do you sing to it, or rock it, or walk with it ? By no means ! 
We put it in the crib, kindly cover it, and let it go to sleep 
when it gets ready. It kicks up its heels, plays with its pink 
toes, and soon drops off to sleep. 

To be in the highest health, babies should sleep all night 
like other people, and this should be taught them the first 
week of their lives, by simply letting them alone. The band- 
age, shirt, pinning blanket, skirt, and double gown are dis- 
carded. You could not sleep with all this load of clothing, 
nor can the baby. 

When put to bed after the last nursing, let it absolutely 
alone until six o'clock in the morning. But what shall I do if 
it cries ? It will not cry, it has a healthy father and mother, it 
has a good supper, it has a nice warm nest to lie in, it is a rea- 
sonable baby and will not cry for nothing. ** But," says thi 
nurse, with a wise shake of the head, ''babies will cry some- 
times." Yes, kittens mew, dogs bark, and colts whinny, but 
no hurt comes to them from these healthful exercises. They 
do not rupture, nor will the bab}^, grandmother to the contrary, 
notwithstanding. If you pick that little one up to-night, you 
will have to to-morrow night, and if you pick it up to-night and 
to-morrow night, the mother must do it three hundred and 
sixty-five nights, and she should not be thus punished for 



SLEEP; HOW TO_ SECURE IT. 73 

being a mother. This is a perfectly easy thing to do if you 
begin the first night, and you can teach the baby to sleep all 
night, like other people, before it is a week old. What a bless- 
ing this habit is to mother and child, only those know who 
have tried both ways. 

Baby's crib should be open work, to allow ventilation. The 
mattress of hair should have over it a pilch and a sheet. What 
kind of a pillow shall we have ? Well, let us have a pretty 
pillow, with a lace border and a blue ribbon run in about the 
edge to put into the crib when baby is not there. What, can't 
I have a nice, downy pillow for my baby to sleep on ? Well, 
I will tell you something, and then you may decide for your- 
self. 

Baby is put into a crib with a soft, downy pillow, it settles 
down, sleeps soundly, the room is warm, and when it wakes, it 
is all wet behind the ears and back of the neck. It is taken 
up and carried into the next room to see company, it takes 
cold and to-morrow you send for the doctor. Again, this 
elevating of baby's head has a tendency to produce round 
shoulders. If you would have the baby grow straight and 
handsome, let him sleep on a straight, flat bed for the first few 
years. Babies love to lie on their stomachs; this healthful 
and enjoyable position they cannot assume on a pillow. 

The covering of the baby should be light and warm, never 
burdensome. If you put your hand on the neck, and find it 
wet with perspiration, you may be sure it is too warmly cov- 
ered. If at any time during the year you find the baby cross 
and fretful, stop and think and say to yourself, " Perhaps I am 
not sleeping the little one as much as I ought to; I will give 
more attention to the proper conditions of sleep." In this way 
you will often remedy the whole trouble. 



PART II- 

DISEASES OF THE EYE AND EAR. 



CHAPTER I. 



DISEASES OF THE EYE. 



The eyes of the infant should be carefully and thoroughly 
examined immediately after birth, to determine the probable 
condition of the function of vision, the presence or absence of 
congenital defects, and the possible and not infrequent reten- 
tion of some of the vaginal secretions within the conjunctival 
sac, on the eye-ball, eye-lashes, or upon the surface of the lids. 

The examination thus made may reveal evidence of the in- 
fant's eyes having suffered from inflammation, while yet m utero. 
When present such conditions are the result of syphilis, either 
transmitted from the father direct to the fetus, from the ac- 
quired syphilis of the mother, or from heredity of one or both 
parents. The affections thus occurring frequently destroy the 
sight, partially or wholly, before birth, and usually leave such 
objective changes in the eyes as to enable us to determine the 
part which has been diseased and also the extent of the inflam- 
matory changes. 

Following an attack of fetal iritis, we shall find the iris vary- 
ing in color from that normal blue of all infants immediately 
after birth, the pupillary opening perhaps blocked with lymph 
or adherent to the lens capsule, the latter better shown by the 
immobility of the iris, under the influence of light varying 
in intensity. 

The cornea may present a whitish, opaque appearance, the 
result of inflammatory changes in its substance, the extent of 
the loss of transparency presented, together with its location in 
the cornea, determining a proportionate loss of vision to the 
infant. 

When an inflammation of the choroid has occurred in fetal 
life, no external expression of it is visible in the eyes until some 
days after birth, when the wandering or oscillatory movement 
of the eye-balls indicates to the observant physician, that the 
function of sight is impaired, and an ophthalmoscopic examina- 
tion usually reveals changes in the choroid and retinae, sufifi- 
(74) 



DISEASES OF THE ETE AND EAR. 75 

cient to account for the restless movements of the eyes of the 
infant in its instinctive effort for better vision. Thus, within 
its first month of life, in its natural endeavor to find, aside from 
the impaired central and most sensitive, some other portion of 
the retina which has been less affected by the choroiditis from 
which it has suffered before birth, to this apparently choreic 
motion, the term nystagmus has been given. 

The normal visual power of the infant at the time of birth 
is so far without a standard ; yet the function of sight of the 
new-born child is without doubt a progressive one. 

Some years ago in a series of experimental observations 
upon the infants under the care of Dr. George E. Shipman at 
the Foundlings' Home, I was able to satisfy myself, that during 
the first month, the infant has but little vision except that of 
light perception. The impressions of objects made upon the 
infantile retina seemed to be absolutely of no value, except as 
they tended to excite in a general way, the ganglionic cells of 
the optical area of the cortex which constitutes the visual sphere. 

In these experiments, and in the light of later investigations, 
the observations noted by me at that time, tend to determine 
the fact, that even in the first weeks of infantile life the excita- 
tion of the optic nerve-fibers, resulting from the impression 
upon the retina of bright lights, and such necessarily undefined 
forms of objects, which might be projected upon the infantile 
retina, are at the same time sufficient to excite a stimulus of 
the ganglionic cells of the optical area of the cortex so as to 
come within the domain of consciousness and tend toward its 
development. 

In the early life of the infant, I am satisfied that months 
must pass before any permanent changes may result in the 
ganglionic area of the cortex, which will enable the child to 
retain memory pictures of the things seen. 

The power of the reproduction of well-defined optical mem- 
ory pictures is attained ordinarily only after the first or second 
year of life, and is dependent upon the frequent repetition of 
the same retinal excitation for the objects seen. As the infant 
increases in age, the repetition of similar images becoming more 
frequent and the objects more varied, a rapid development of 
its power of visual consciousness results, and the increase of the 
power of reproduction by the memory of those things which 
the child has seen, follows. 

The retina, optic nerve, and the ganglionic cells of the cun- 
eus portion of the brain in the infant, with their imperfect 
receptive, conductive and absorptive powers, while sufficient to 
receive perhaps the more or less imperfect image on the retina, 
and slowly transmit it through the optic nerve to the brain, it 



76 THE DISEASES OF CHILDREN. 

is probable that only a transient impression upon the optical 
memory cells of the cortex results. Imperfect as the stimulus 
and its transmission may be at this age, it is at the same time 
of great value in the excitation of these memory cells, which 
later have much to do with the mental and even the physical 
development of the child. 

The new-born infant may exhibit, at birth, some of those 
anomalous conditions of the eyes, which occur from arrested or 
imperfect development which are classed as congenital defects, 
which, when present, may have a visual, cosmetic, or surgical 
value. 

To the physician who has conducted the infant into this 
world without other evidence of monstrosity, there is perhaps, 
nothing more appalling than the presentation to the nurse, or 
the mother, of a child without eyes (anopthalmus). 

The infant emerging from the inner-world of the mother to 
the outer-world of light, separates its lids involuntarily for the 
purpose of stimulating its imperfect retina by the admission of 
light to further its development. If the lids do not open at birth 
and thus expose the cornea and pupil to the observation of the 
physician, he must determine whether the fault lies in an ina- 
bility to open the eyes because of inervation of the levator of 
the upper lid (congenital ptosis) ; or because from arrested de- 
velopment the fissure of the lids has not been completed and 
their free margins remain united (ankyloblepharon) ; the lat- 
ter condition at birth frequently covering the defect due to 
absence of the eye-balls (anophthalmus); or their imperfect 
development when the eyes are abnormally small (microph- 
thalmus). 

Among the other defects to be noticed are the absence of the 
eyelids (ablepharon) which occurs only in monstrosities; the 
displacement of the normal opening of the lids from a hori- 
zontal position to an angular one (ectopia tarsi), which gives 
the child a Mongolian aspect ; or when there is a vertical fis- 
sure of the lids (coloboma), usually the upper being the one 
affected, although the lower or even both may exhibit this 
defect. 

Again it may be noticed that one or both lids may be in- 
verted (entropion) or there may be an over-development of the 
cilia and two lines of eyelashes (distichiasis) be present, the 
inner row causing irritation of the cornea and eyeball. 

Sometimes a redundant fold of skin may show itself at the 
bridge of the nose, and by its fullness cover the inner canthus 
of each eye sufficiently to cause a deformity and perhaps inter- 
fere with the vision and the opening of the lids. This deform- 
ity (epicanthus) may be lessened or dissipated in some cases 



DISEASES OF THE ETE AND EAR. 77 

by the removal of a vertical elliptical piece of the skin at the 
dorsum of the nose, and yet if the fold of skin is not too great 
in flat-nosed children, the deformity may disappear without 
operation in from four to six years, with the development of 
the nose bridge. 

Vascular naevi or other birthmarks may exhibit themselves 
and require surgical treatment soon after birth, owing to their 
extent, or later, when in the judgment of the surgeon their dis- 
appearance with the development of the child is not probable. 

The presence or absence of the lachrymal apparatus is rarely 
noticed immediately after birth, and it may be weeks or months 
later that the congenital defects of imperfect development of 
the puncta, canaliculus, or lachrymal ducts cause attention by 
the overflow of tears or the presence of pus or muco-pus at the 
inner canthus. The lachrymal gland in rare cases is found to 
be absent or undeveloped ; the usefulness of the eye, however, is 
not necessarily impaired by its absence. 

If, as is rarely the case except in lying-in asylums, found- 
lings' homes, or other similar institutions, a careful examination 
of the eyes of the new-born is made by a skilled medical attend- 
ant, other defects arising from arrested development which im- 
pair the sight are often found present in eyes which to the less 
skilled observer would pass for normal eyes. 

The iris may be absent (irideremia), or show a cleft, the fis- 
sure being generally below (coloboma of the iris), a displace- 
ment of the pupil, inward, outward, upward, or downward 
(corectopia), or there may be more than one pupil (polycoria), 
in some cases the abnormal position of the pupil causing both 
imperfect vision as well as a cosmetic defect. 

With the opthalmoscope we look into the interior of the eye 
and find where nature failed to complete its work for the indi- 
vidual, as in the pupil, which should be free of all obstruction 
for the purpose of vision, shreds of membrane are seen to 
stretch across its area (persistent pupillary membrane) and which 
interfere more or less with the ultimate vision of the infant. 
It may be found that the lens is not in its normal position 
and that by some freak of development it is displaced (luxatio 
lentis congenitalis), or that certain layers of its tissue are opaque 
and a diagnosis of lammellar or zonular cataract is made. Not 
infrequently the whole lens is opaque at birth and congenital 
cataract should be diagnosed. 

If the lids, cornea, iris, lens or vitreous are normal, we may 
find on ophthalmoscopic examination that there may be evi- 
dence of arrested development in the posterior portion of the 
eye, perhaps what is called a persistent hyaloid artery, a blood 
vessel running from the optic disk to the posterior portion of 



78 THE DISEA SES OF CHILDREN. 

the lens, originally intended for the development of the latter, 
but which failed to be absorbed and thus by its presence 
interferes with the vision of the eye ; or there may be an 
opening in the choroid (coloboma) which has impaired the 
development and sensibility of the overlying retina at this 
portion. 

It is not unlikely that we may find in the investigation of the 
depths of the eyes, that more or less of the optic nerve fibers, 
which enter the eyeballs through the opening in the sclera, 
have not been denuded of their opaque sheaths and present to 
our view a radiating opaque white mass which we have learned 
to recognize as opaque optic nerve fibers. 

In some cases deposits of pigment may be observed upon or 
around the optic disk, but like the opaque nerve fibers, have 
no special relation to the visual functions unless the lesion is 
an extensive one. 

In infancy and childhood, there are certain acute diseases of 
the eye, which require early recognition on the part of the 
physician, who should be able to diagnose and prognose the 
condition, even if he does not feel that he can do, from want of 
experience, what a specialist might. The ophthalmic surgeon 
is only a specialist because of years of practice confined to his 
department of medicine, in which he has acquired a knowledge 
or a technique from the large number of special eye cases which 
come to him, that the general practitioner cannot avail him- 
self of. 

Following the examination of the eyes of the infant as out- 
lined above, if we should find upon the lids, eyelashes, or within 
the conjunctival sac of the eye any extraneous matter and our 
search for it should be the more thorough, if we have suspicion 
or knowledge of a specific disease of the genital organs of the 
mother, or, if a marked or acrid leucorrhoea exists, the presence 
of such matter endangering the eyes by possible inoculation. 
Such conditions, when present in the mother, are too often fol- 
lowed by destructive inflammation of the eyes of her infant. 

Ophthalmia Neonatorum, is a term applied to one of the 
most frequent of the inflammations of the eye in infancy, and 
is a purulent inflammation of the conjunctiva of the new-born 
child. It is a disease which is usually violent in its outset and 
rapidly destructive of sight. 

While in the last few years, although scientific medicine has 
reduced the percentage of blindness resulting from it, from 
seventy to thirty-five, it still furnishes the largest number of the 
inmates of our blind asylums. 

Such being the case, it is necessary that the physician who 



PROPHYLAXIS— SYMPTOMS; DIAGNOSIS. 71> 

attends mother and child, should be alert to discover the con- 
dition of the infant's eyes, and also to avoid it, if possible, by- 
proper care of the mother before parturition. 

Prophylaxis. — It is important and necessary to exercise 
the most rigid care to prevent infection of the eyes of the in« 
fant, by careful disinfection of the vagina before and during 
parturition in all cases where a specific or acrid leucorrhoea, 
whether cervical or vaginal, exists in the mother. 

When the mother presents an acrid leucorrhoeal or gonor- 
rhoeal discharge, or a vaginal discharge of whatever character, 
the most scrupulous attention should be given to its correction 
prior to confinement. The use of cleansing lotions of large 
quantities of warm water, containing carbolic acid,boracic acid, 
sulphate of zinc, or glycerole of tannin, for several days prior 
to confinement will undoubtedly lessen the danger of infection. 
After the birth of the child, and before the cord is severed, the 
physician should at once cleanse the eyelids with bits of soft 
linen, or absorbent cotton ; remove all secretion from the cilia, 
and wash the eyelids and surrounding parts in a saturated 
solution of boracic acid. 

When we have reason to suspect that danger of inocula- 
tion is probable, we should, as soon as the child has been other- 
wise cared for, evert the lids to discover and remove any of the 
unctuous material mixed with leucorrhoeal discharge which 
may have insinuated itself beneath the lid, and found a resting- 
place upon the folds of the conjunctiva. 

Symptoms and Diagnosis. — The most typical cases of oph- 
thalmia neonatorum occur from twelve to seventy hours after 
birth. Usually before the third day we find the eyelids some- 
what reddened, slightly swollen, and a slight flow of tears. 
Eversion of the lids will show bright red transverse lines occupy- 
ing the middle of the palpebral conjunctiva ; shortly after this, 
the edges and angles of the lids become red, and perhaps pain- 
ful on pressure. The ocular conjunctiva is next to become 
involved ; it appears bright red, and the swelling of the lids in- 
creases. The discharge which at first was almost entirely of 
tears, now becomes serous, and gradually assumes the appear- 
ance of turbid whey. There is considerable photophobia, which 
causes the infant to close the lids tightly, so that some diffi- 
culty is experienced in opening them. This closes the first 
stage. The second stage, or that of suppuration, is ushered in 
usually by a marked increase in the swelling of the lids. This 
swelling increases so rapidly that often in twenty-four hours 
they cannot be separated without considerable force. The 
upper lid usually overlaps the lower one, and, in most cases, is 



80 THE DISEASES OF CHILDREN. 

SO stiff that it is difficult or impossible to turn it. On separat- 
ing the lids the exposed conjunctiva is thickened, perhaps 
raised in folds, and of a diffused bright red hue through which 
the sclera can be dimly seen. At first there is a muco-purulent 
coating over the entire conjunctival surface; the discharge 
soon becomes more abundant and decidedly purulent, and later 
is thick and creamy. The effusion into the conjunctiva is gen- 
erally serous and causes chemosis or swelling of the conjunc- 
tiva of the eyeball and protrusion of the lids, but in some cases 
contains much fibrin, and the conjunctiva presents a raised and 
resisting surface in that portion ; this condition arises more 
particularly in the course of gonorrhoeal infection, and is, of 
necessity, very grave, owing to the danger to the cornea from 
the compression of the vessels which supply it. When the ef- 
fusion is very great, the swelling of the ocular portion may 
extrude between the lids, and the palpebral swelling causes 
eversion of the lids, the latter giving rise to a spasmodic action 
of the orbicularis, or blepharospasm, which, by increasing the 
pressure upon the eyeball, causes increased danger to the 
cornea. 

As the inflammation increases the secretion of pus becomes 
enormous, considering the small area of the suppurating surface. 
The free edges of the lids are stuck together by the discharge 
drying upon them, and their separation causes the discharge to 
gush out with some force, and oftentimes with danger to the 
operator. The cornea is thus kept macerating in the impris- 
oned pus. The cutaneous surface of the lids is livid, traversed 
by enlarged veins from the passive congestion. Early in the 
second stage it is usual to notice unmistakable signs of pain. 
There may be some marked febrile reaction, the child becomes 
restless and refuses the breast. If the local affection is slight, 
the child usually thrives. In the majority of cases of ophthal- 
mia there is no further advance of the disease ; the inflamma- 
tion having reached its height now begins to subside, and 
usually results in complete recovery, without sequelae. Some 
cases, however, pass into a chronic catarrhal inflammatory con- 
dition, and in others the papillae become hypertrophied or true 
granulations result. If the cases do not end here, irreparable 
damage results from the third stage which is entered upon, in 
which we have involvement of the cornea in the inflammation. 
This complication is more frequently the result of gonorrhoeal 
infection or of badly treated or neglected cases. 

The cornea may exhibit the effect of the destructive process 
at small points or over its whole surface. The corneal affection 
usually appears in from eight to ten days after the disease has 
become established. The corneal epithelium is lost from con- 



PROPHTLAX IS— TREATMENT. 81 

stant maceration in the pus, and the cornea presents at first a 
hazy or milky appearance, which soon becomes yellowish and 
finally ends in complete suppuration, rupture of the cornea and, 
perhaps, loss of the lens, extrusion of the iris and atrophy of 
the bulb. If the disease is arrested before suppuration of the 
cornea is complete the eye recovers with a nebulous cornea, 
presenting much the appearance of ground glass ; this con- 
dition may clear up very much owing to the activity of the 
absorbents in infancy, a result which may be hastened by the 
assistance of certain homeopathic remedies. 

In another class of cases we may have one or more minute 
grayish points of corneal infiltration and softening which give 
rise to ulceration and perforation. In others still, the whole 
cornea may slough, as the result of the strangulation of the 
vessels by the chemotic swelling, so that on the second or 
third day the eye is entirely destroyed. In the milder cases of 
strangulation of the blood-vessels of the cornea which nourish 
it, there may be one or more rapidly spreading central or mar- 
ginal ulcers, which appear as if portions of the cornea had been 
chipped out, with clean cut edges and transparent bases which 
are difificult to detect unless viewed by oblique illumination. 
These are more difficult to heal than the others ; the edges 
become rounded, blood-vessels develop in them and they rap- 
idly fill up. 

As a rule, both eyes are affected simultaneously, or in rapid 
succession ; at times, one eye is infected and the other remains 
free. In all cases the eye should be carefully examined by the 
medical attendant, and to do this, the discharge should be care- 
fully removed from the lid margins and lashes, and then the 
eyelids separated by the fingers applied above and below, or if 
necessary, small retractors should be used ; having in this man- 
ner obtained a view of the whole anterior portion of the eye- 
ball, the cornea should be thoroughly examined. The duration 
of the disease is from three to six weeks, and much longer if 
improperly treated, or neglected. 

Treatmefit. — The eyes should be shaded from the light, but 
it is not necessary to confine the infant to a darkened room ; 
rather place it in a light and well-ventilated apartment. The 
success of the treatment depends upon the frequent removal of 
the discharges, the eyes being constantly cleansed with scraps 
of old linen or bits of absorbent cotton, and the further cleans- 
ing of the eyes with solutions of chlorine water diluted one-half, 
boracic acid (gr. X. ad /^i.), or arg. nit. (gr. i. ad /^i.) injected 
into the eye from an eye-dropper, and the use of vaseline to the 
lid edges will be sufficient to carry the majority of cases to a fa- 
vorable termination without other remedies. The use of cold 
D. C— 6 



82 THE DISEASES OF CHILDREN. 

compresses is not applicable to such young infants, but in case 
corneal affections appear, frequent bathing of the eyes with 
warm water every five minutes during the day, and every 
quarter-hour at night, and the use of a solution of atropine 
(gr. yi ad /§i.)> o^ie drop every three hours, will be indicated. 
The careful following of the directions for the removal of 
the discharge and the administration of arg. nit., 6th to 
30th, puis., mere, or hepar sulph., will be sufificient to bring 
the cases to a favorable termination. Other remedies may be 
useful and their indications will be found under Conjunctivitis 
Purulenta. 

Catarrhal Conjunctivitis of the new-born infant often 
presents itself within the first weeks of its new life. The 
secretion of the inflamed conjunctiva is often muco-purulent, 
instead of being mucoid ; the lessened intensity of the symp- 
toms enables us to differentiate this affection from that just 
described. 

Etiology. — The inflammation seems to arise from exposure 
to varying temperature, to want of proper protection during 
the bath, the want of proper hygienic surroundings, careless- 
ness upon the part of the nurse in cleansing the eyes or the 
transferrence of foreign matter to the eyes from the fingers or 
cloths used by the attendant. Undoubtedly the exposure of 
the eyes of the infant to strong and bright lights, occasions 
in some cases the inflammatory reaction. 

Symptoms. — There is usually some swelling of the lids, the 
eyeballs present a more or less bloodshot appearance. There 
is also anxiety and restlessness of the child due to the discom- 
fort of the eyes, which interferes with its sleep. 

The discharge, at first watery, becomes mucoid, collects upon 
the lids and eyelashes and causes their adherence. 

The discharge never presents that yellowish color, creamy 
consistence nor quantity that is found in the purulent conjunc- 
tivitis. 

Prognosis. — As the symptoms are more mild than in the 
purulent form, the danger to vision is slight, as the cornea is 
seldom affected, and the disease is capable of spontaneous 
cure in the majority of cases, within a week or two of its 
inception. The greatest danger is from a possible chronicity, 
which may occasion the development of true trachoma or 
granular lids later, as is commonly the case in ophthalmia 
neonatorum. 

Treatment. — The use of some mild collyria, such as the 
borax, boracic, alum or tannic acid glycerine, together with the 
internal use of aconite, euphrasia, hydrastis, sulphur, mercu- 



PHL rC TEN UL A R C ON J UN C TI VI TIS. 88 

rius, or argent nit., are sufficient to hasten the cure and lessen 
the danger of any chronic condition resuhing. 

Phlyctenular or Pustular Conjunctivitis is a recur- 
rent form of inflammation, characterized by the appearance of 
one or more vesicles or papules upon the ocular conjunctiva, 
supposedly around the terminal filaments of the branches of the 
fifth nerve, and often occurring near the cornea. Each papule 
or phlyctenule forms a small patch of localized congestion to- 
wards which converge a leash of vessels which can frequently be 
traced back to the folds of the conjunctiva. These phlycten- 
ules may present a semi-transparent or yellowish elevation or 
be more flat, large, and give the appearance of a gelatinous in- 
filtration at that point. There may be one or many scattered 
over the ocular conjunctiva, or aggregated at the corneal margin, 
or they may encircle it and appear upon the cornea also. In a 
few days the vesicle which forms the summit of the phlycten- 
ule, ruptures and leaves a shallow ulcer with a yellowish base 
which heals in a few days. In some cases small points of con- 
gestion only, appear and after a short time subside without the 
formation of a vesicle. The pain is usually not severe, the 
photophobia or dread of light variable, and in some cases very 
slight, in others, intense and accompanied by severe blephar- 
ospasm. The secretion is commonly scant and mucoid in 
character. 

The disease shows a great tendency to recur and the phlyc- 
tenules appear in successive crops after the lapse of weeks or 
months. They are very prone to appear in the winter and 
spring. Children have a peculiar liability to the disease, as it is 
only rarely seen in adults, and may be considered as indicative 
of some derangement of the general health. It is common to 
delicate and ill-nourished children, particularly those who live 
upon an almost exclusively starch diet, or use tea and coffee. 

Treatment. — The treatment consists in the improvement 
of the general tone of the patient, and the restriction of such 
nerve stimulants as tea and coffee. The patient should be 
urged to live upon a mixed diet, as many cases cannot be cured 
until a moderate amount of nitrogenous food enters into the 
daily nourishment. External applications are rarely necessary, 
as the cure is much more rapid and permanent by the use of in- 
ternal remedies than with topical applications. Of the latter, 
those which are generally recommended are the yellow oint- 
ment, a small bit of which is introduced between the lids and 
allowed to melt upon the conjunctiva, calomel or flowers of 
sulphur dusted upon the phlyctenule, or solutions of mere. nit. 
dropped into the eye. 



S4: THE DISEASES OF CHILDREN. 

REMEDIES. 

Sulphur. — Very frequently indicated in cases occurring in 
-scrofulous children. Its sphere of action is very wide and 
suits a great variety of cases of pustulous inflammation of the 
conjunctiva, and is particularly indicated when there are sharp, 
darting, lancinating pains, or as if pins and needles were sticking 
in the eye during the day, or if the pains aggravate after mid- 
night. There may also be itching, often a thickened condition 
of the lid and much rubbing of the eyes. The photophobia is 
variable and may be quite marked in the morning. The lach- 
rymation is usually profuse and the lids generally stick together 
on awakening. 

There is often an eczematous condition of the lids, face and 
head, and general aggravation from the application of cold water, 
or from bathing the eyes. 

Pulsatilla. — The phlyctenules are more frequently of the 
small variety, but often numerous ; the photophobia or pain is 
commonly slight and the redness variable. The lachrymation 
and discharge are moderate and bland, although it is not con- 
tra-indicated if the secretions are profuse. Particularly suit- 
able to the blonde women and children upon whom pulsatilla 
seems to have so good an action. 

Mercurius Sol. — A valuable remedy in many cases of phlyc- 
tenular inflammation in strumous or syphilitic children. There 
is usually marked redness of the conjunctiva, and violent pho- 
tophobia, so that all light must be excluded, and the discharge 
usually thin and acrid. The pains are severe and neuralgic in 
character, affecting the temporal side of the head and face. 
They are variously described as burning, sharp, tearing, and 
lancinating, and aggravated in the evening and from the expo- 
sure of the eyes to artificial light, by heat and damp weather, 
while there is a temporary relief from application of cold water 
to the eyes. The lids are often thick and swollen and spasmodic- 
ally closed and excoriated by the discharge. 

Merc. Cor. — Indicated in the aggravated form of inflamma- 
tion occurring in scrofulous children. The symptoms are much 
more marked than in the other preparations of mercury, the 
pains, photophobia, lachrymation, all being aggravated ; the 
nostrils are often excoriated by the acrid discharge from the 
eye, passing down into the nose. 

Mercurius Dulcis. — Although calomel is used very exten- 
sively by the old school in scrofulous ophthalmia, it is but rarely 
applicable to phlyctenular inflammation ; some cases, occurring 
in pale, flabby subjects, with excoriation of the nose, and swell- 
ing of the upper lip, have been benefited. 



REMEDIES. 85 

Mercuriiis Nit. — This remedy, recommended by Dr. Llebold, 
was used by him with remarkable success in a great variety of 
cases of phlyctenular inflammation. It seems to suit severe as 
well as mild affections, acute or chronic, with or without much 
photophobia, and in some cases presenting severe pain, in 
others where the pain is absent. It may be used both inter- 
nally and externally. If externally, ten grains of the first deci- 
mal trituration are to be dissolved in two drachms of water and 
applied by means of a camel's hair brush to the phlyctenule 
two or three times a day. 

GrapJiites. — This is one of the most valuable remedies we 
have for all forms of phlyctenular inflammation. It is useful 
in both the acute and chronic forms, particularly in cases where 
there is a marked tendency toward recurrence. It is specially 
indicated in scrofulous cases, or with exanthematous eruptions 
about the head or behind the ears, particularly where the erup- 
tions are glutinous, fissured and bleed easily. The photopho- 
bia is usually very marked, and the lachrymation profuse, 
although in some cases nearly or entirely absent. There is 
generally a greater aggravation from sunlight than from gas- 
light, and in the morning, so that often the child cannot open 
the eyes before nine or ten o'clock. The conjunctiva is fre- 
quently very red, and the discharges are muco-purulent, con- 
stant, thin and excoriating. The pains are variable and not 
characteristic, the lids are sore, red and agglutinated in the 
morning, or else covered with dry crusts, while the external 
canthi are fissured and bleed easily upon opening the eye. 
There may be also an acrid discharge from the nose accom- 
panying the eye affection. 

Calc, Carb. — Phlyctenules occurring in fat, unhealthy chil- 
dren, with pale, flabby skin and enlarged glands. The pho- 
tophobia is often excessive, and the lachrymation very great 
and often acrid. The redness and pains (sticking in character) 
are variable and the lids perhaps swollen and glued together in 
the morning. 

Calc. Sulph. — Will prove exceedingly valuable in many cases 
when the general symptoms of calcarea are present with en- 
largement of the cervical glands. The lower attenuations 
should be used. 

Hcpar SulpJi. — Is adapted to phlyctenular inflammation oc- 
curring after measles, or in strumous children, where there is 
intense photophobia, lachrymation, an injection of the con- 
junctiva with swelling of the lids, sensitiveness to touch and a 
desire to have them covered, and when the external canthi 
bleed easily on opening them. 

Arsenicinn. — Cases occurring in thin, ill-nourished children, 



86 THE DISEASES OF CHILDREN. 

without marked inflammatory symptoms. There is usually 
intense photophobia, and profuse, acrid lachrymation. The 
phlyctenules tend to form ulcers which extend superficially 
and take on an indolent character. 

Rhus Tox. — Where there is excessive photophobia, lachryma- 
tion and spasmodic closure of the lids. There is generally a 
vesicular or pustular eruption upon the eyelids or face. Antim. 
tart., ipec, kali.bi., mez., crot. tig., euphrasia, sepia, and 
baryta, are also serviceable in phlyctenular conjunctivitis and 
will give prompt results when indicated. 

Ulcers of the Cornea are of frequent occurrence among 
children, but less so among infants. The most simple form 
of ulceration of the cornea is that exhibited by a grayish- 
white spot which is usually located at the center of the cornea. 
It is often not examined early enough to show its flattened 
conical elevation presented in the first stage, the later develop- 
ment exhibiting a slight depression of the cornea with perhaps 
little of the grayish infiltration which marked its beginning. 

The photophobia, congestion of the eye and swelling of the 
lids, are variable symptoms which also seem to bear by their 
intensity no ratio to the duration or extent of the ulcer. 

As these ulcers commonly attack the central portion of the 
cornea, their danger to vision is great, as they usually attack 
one eye at a time, and tend to recur in the same or the other 
eye. The opacity or scar thus left is greater in those cases 
where the repeated ulceration has caused the greater loss of 
transparency. The central location of the opacity causes such 
a marked interference with the function of vision in many cases 
as to destroy the sight entirely. In cases where the ulceration 
is acute in its course and heals rapidly, the destruction of tissue 
and loss of transparency is much less than in those which pre- 
sent a chronic and recurrent character. In some cases the 
repair of the lost substance is not comipleted and a flattening of 
the curve of the cornea occurs at the site of ulceration which 
interferes greatly with the vision. 

It should be borne in mind that these ulcers now and then 
tend to spread, and take on a suppurative character, when this 
occurs the danger becomes very great. The original infiltra- 
tion sometimes passes rapidly to the formation of an abscess 
of the cornea, with extensive destruction of tissue and loss of 
the eye. When an abscess is forming, a small spot slightly 
raised appears, accompanied by much pain and congestion. It 
enlarges rapidly, becomes yellow in color and commonly rup- 
tures outward, leaving a more or less deep, round ulceration 
with a yellowish, purulent infiltration, which may ultimately 



PHLYCTENULAR ULCERS. 87 

destroy the cornea. Sometimes the abscess may open into the 
anterior chamber, and hypopyon, a collection of pus in this part 
of the eye, results. 

The causes which give rise to these destructive attacks are, 
in my opinion, invariably those due to malnutrition, defective 
nourishment, and a strumous habit, with bad hygienic sur- 
roundings. 

Phlyctenular Ulcers (phlyctenular keratitis, pustular 
ophthalmia, marginal keratitis, strumous or scrofulous oph- 
thalmia) constitute the larger number of ulcerations of the 
cornea occurring during childhood. 

The causes which give rise to them are the same as those 
which have already been indicated as producing the central 
ulcerations. 

The symptoms are first, photophobia, that one which is usu- 
ally most marked and which is common to all corneal inflam- 
mations or ulcerations. The dread of the light varies with the 
development of the phlyctenule or pustule upon the cornea, 
being often slight in the first stage and moderate later, or in- 
tense to a degree that there is no place sufficiently dark to en- 
able the child to open its eyes. 

This over-sensitiveness to light causes, as a reflex, a marked 
spasmodic closing of the lids. The blepharospasm is often one 
of the most painful and most annoying of the symptoms which 
occur in this disease. The child is inclined to lie with its face 
buried in the pillow, or the lap of the mother, or seek the dark- 
est corner of the room and cover the eyes with the hands. 

A pustular eruption is often present on the face and lids. 
The constant discharge of mucus from the nose, owing to the 
irritating qualities of the secretion from the eyes which passes 
into the nose, gives rise to the common idea that the child is 
suffering from a cold in the head. 

If the lids are separated, and it often requires considerable 
force upon the part of the examiner to do so (unless he has 
instilled a drop of a 2-per-cent. solution of cocaine at intervals 
of two or three minutes for two or three times), we find per- 
haps only a single spot upon the cornea with a triangular- 
shaped injection of blood-vessels radiating from it. There may, 
however, be several of these phlyctenules situated upon differ- 
ent portions of the cornea or arranged in ring-shape at the 
margin of the cornea, often encircling its whole periphery. 
These pustules vary in size from a small point to those of two 
or three millimeters in diameter. They are due to exudation 
of serum beneath the epithelial layers of the cornea and usu- 
ally about the terminal filaments of the branches of the fifth 



88 THE DISEASES OF CHILDREN. 

nerve which supply it. The phlyctenule, bleb or pustule thus 
formed by the exudation is raised above the surface of the cor- 
nea, and contains within its cavity serum, a few leucocytes, 
or some white corpuscles. Its top may appear yellow, but 
more often when seen the surface is abraded and it has a gray- 
ish and aphthous look. The eruption may be resolved without 
breaking down in some cases, but the majority rupture and 
ulcers result. The rupture is followed by rapid healing in 
some cases. More frequently, however, the ulcer takes on a 
sluggish condition and becomes a source of much discomfort to 
the child and danger to its vision. 

The congestion of the eyeball and cornea as well as the pain 
vary extremely in degree in different cases, the congestion 
being usually confined to that part of the sclera immediately 
surrounding the cornea, but may involve the whole of the sclera 
as well. 

The pain is usually referred to the parts about the eye in 
those cases when the child is old enough to describe it, or in- 
volves the whole head when there is great photophobia and the 
eyes are exposed to the light. 

Treatment should consist, first, in the attempt to correct 
the nutrition by regulation of diet, the increase of the nour- 
ishment by the addition of those condensed foods which are 
now so well prepared and which are usually readily digested 
and assimilated. My preference in those cases has been for 
those that are made from beef. Murdock's Food, Bovinine 
and certain of the beef extracts are of the greatest value 
in supplying to the blood those elements which are so neces- 
sary for the protection of the cornea, which derives its nourish- 
ment only indirectly from the blood-vessels, so that if the blood 
is not in a well-nourished state, by the time it reaches, in its 
diluted condition, the central portion of the cornea, there is not 
enough nourishment in it to maintain the vitality of the part 
and the ulceration and destruction begin. 

Second, in the effort to accomplish an early repair of the 
ulceration by such local applications and measures as may be 
deemed expedient. Among the possible aids in this direction 
may be mentioned the probable necessity of keeping the eye 
quiet by bandaging in the effort to hasten the healing process. 
As a rule, I do not advise the bandaging of the eyes of very 
young children except in special cases, as its good results depend 
much upon the judgment and experience of the medical attend- 
ant in these cases. In childhood and youth the bandage is 
likely to do more good and less harm than in infancy. The 
objection to close bandaging is due to the confinement of the 
secretions, often acrid, within the eve, which thus increases 



PHLYCTENULAR U LCERS— TREATMENT. 81) 

rather than diminishes the inflammatory process and the ina- 
bility of the attendant to properly readjust the bandage when its 
removal may be so often necessary for the purpose of instilling 
the collyrium (boracic acid grs. viii. to/5i.) which is intended 
to lessen the irritation arising from the increased or changed 
secretion, or the application of lotions (chlorine water diluted 
one half, saturated solution of boracic acid, or bi-chloride sol. 
I to lom), intended to act as germicides and thus lessen the 
danger of further infective extension of the ulcerative process. 

Third, to stimulate the healing of the ulcers, especially in 
those indolent cases which cause all so much anxiety, by such 
applications as calomel, finely divided flowers of sulphur, 
which are gently dusted upon the ulceration, or the use of a 
minute portion of an ointment made of cosmoline, 3 i ad grs. ii. 
hydrg-ox-fiav., which is introduced between the lids and rubbed 
upon the eyeball. 

Fourth, to relieve the photophobia by the use of smoke- 
tinted goggles or in less severe cases the visor-eye-shade may 
enable the child to get that stimulus from light, fresh air and 
exercise that it most needs and without detriment to its eyes. 
The pain should be relieved as far as may be possible by the 
occasional use of atropine solution {yi gr. to 2 gr. to the/^i.), 
when the ciliary congestion is marked, or much relief may 
be obtained from hydro-chlorate of cocaine (2 per cent. sol. a 
drop once or twice a day). 

Fifth, benefit sometimes follows the application of hot fomen- 
tations or poultices ; the latter, however, should never be applied 
except when directed by the ophthalmic surgeon, as their use 
is more likety to do harm than good ; poultices being usually 
indicated only in those cases where the cornea presents an 
abscess of consideratable extent, a suppurative ulceration, caus- 
ing rapid destruction or a necrotic condition is imminent. In 
some cases it may be necessary to apply the electric cautery in 
the effort to limit the destructive process. In all cases where 
the physician is in doubt about the necessity for, or the value 
of topical applications which in his judgment might be detri- 
mental, it is better to await for a day or two the result of the 
internal medicines which he has prescribed, as in some of these 
severe cases, it is impossible for those who are skilled by judg- 
ment and experience to advise with certainty those local 
measures which may be best in certain cases. 

The internal medications necessary for the cure of these 
ulcerations of the cornea of children, have a more reaching 
effect than the local measures mentioned and are more rapid 
in their action in controlling and limiting their destructive 
influences. 



90 THE DISEASES OF CHILDREN. 

REMEDIES. 

Aconite. — Superficial ulcers arising from injuries. It maybe 
used both internally and externally. 

Arse7iicum. — Corneal ulcers occurring in weak, anaemic chil- 
dren. They are often superficial and have a tendency to recur. 
The photophobia is excessive and the lachrymation acrid and 
burning. The pains are more frequently burning and aggra- 
vated after midnight. Small grayish central ulcers which 
occur in young children and tend to perforate. 

Aurum. — Vascular ulceration of the cornea and ulcera- 
tions occurring during the course of pannus, or as the result of 
abscess. There is much photophobia, profuse scalding lachry- 
mation and sensitiveness of the eye to touch, and pains appar- 
ently extending from the parts around the eye to the eye, and 
aggravated by touch. 

Calc. Curb, and Calc. Hypophos, — Ulcerations occurring in 
ill-nourished patients which show a tendency to slough, or 
which result from abscess. 

Conium. — Some superficial ulcers without much pain or red- 
ness, but with intense photophobia. 

Graphites. — In some cases of ulceration of the cornea which 
have followed attacks of phlyctenular inflammation of the 
cornea or conjunctiva. 

Hepar SiilpJiur. — A valuable remedy for all ulcers or ab- 
scesses where there is pus in the anterior chamber. There is 
usually a marked sloughing tendency and the pain is throbbing 
and the photophobia intense, while the conjunctiva is often 
red and thickened or chemosed. There is relief generally from 
bandaging the eye and the application of warm compresses, 
although there is great sensitiveness of the eye to touch. 

Ignatia. — Small chipping ulcers without much discomfort, 
which occur in connection with derangements of the digestion ; 
also small pinhole ulcers, which are attended by photophobia 
and sensation as if something was in the eye, in nervous and 
hysterical patients. 

Mercurius. — Often indicated in both superficial and deep 
ulcerations. There is generally grayish infiltration of the base 
and around the ulcer, which is also often vascular. The discharges 
from the eye are profuse, thin and excoriating. There is a 
general aggravation at night. Concomitant symptoms more 
frequently decide upon the particular form of mercury to be 
administered ; the eye symptoms indicating mere. cor. being 
more intense and there is much ciliary injection and pain. 

Merc. Nit. — More useful in those ulcerations which partake 
of a phlyctenular character. 



DIFFUSE KERATITIS. 91 

Merc. Prot. — Ulcerations occurring with pannus ; its efficacy 
in ulcus serpens is very doubtful and it has not proved as use- 
ful as calc. phos. or silicia in these cases. 

Nux Vomica and Pulsatilla suit some cases of superficial 
ulcerations with intense photophobia, and it becomes very dif- 
ficult to differentiate between them when marked concomitant 
symptoms are not present. 

Silicia. — Indicated in some cases of sloughing ulcers of the 
cornea, as in the marginal ulcer, and when small, funnel-shaped 
non-vascular ulcers appear near the center of the cornea and 
rapidly perforate. 

Sulphur. — When the ulceration is indolent and tends to 
slough this remedy will be useful. There is often considerable 
infiltration around the ulcer, but no vascularity. The photo- 
phobia, lachrymation and other symptoms are variable. The 
sharp, sticking pains, which are commonly present and worse 
after midnight, are very characteristic. The subjects are 
strumous and the general condition is indicative of sulphur. 
Many other remedies may have to be consulted for individual 
cases. 

Diffuse Keratitis (syphilitic, interstitial, parenchyma- 
tous, strumous or scrofulous keratitis), is an inflammation of the 
cornea which essentially is a disease of childhood. It occurs 
■commonly between the ages of five and twelve, some cases being 
reported between the second and third year, and very rarely later 
than the fifteenth year, and still much more rare in adult life. 

Etiology. — Inherited syphilis is the undoubted cause of 
this disease, and in children in which it presents itself we have 
the physiognomy, notched teeth, skin, mouth and bones which 
we have learned to regard as positive indications of syphilitic 
inheritance. In the absence of these signs, we may have to as- 
sign as the cause a scrofulous or strumous habit ; or with other 
symptoms it may be coincident with the secondary stage of 
acquired syphilis, the latter, however, being extremely rare. 

Symptoms. — A grayish opacity first shows itself at the center 
of the cornea in the tissue, and gradually extends with increas- 
ing density, until the whole cornea has lost its transparency. 
Again, the opacity may begin at one or more places near the 
margin of the cornea and extend to the center. These changes 
in the cornea which mark the beginning of a chronic inflamma- 
tion of its tissue, and which does not go on to ulceration or ab- 
scess, are ushered in by a preliminary stage, often overlooked. 
of injection of the sclera about the margin of the cornea, and a 
watery appearance of the eye from increased lachrymation. 
The sight is rapidly lost, and if the disease attacks both cor- 



92 THE DISEASES OF CHILDREN. 

neas, as may be the case, though usually the disease is well 
advanced in one before the other is affected, the first symptom 
noticed in young children is the falls the child suffers from, 
owing to its imperfect vision. 

It is rare that more than a few months intervenes before the 
second eye is attacked, and extremely rare that a year or more 
elapses, as the disease is commonly symmetrical. 

In from two to four weeks the cornea becomes so opaque 
that the iris and pupil are no longer seen, and the grayish- 
white appearance looks like ground or frosted glass, its surface 
roughened from the loss of portions of its epithelium. An in- 
flammation of the iris often complicates the attack, and by 
adherence to the lens capsule (posterior synechia), lessens the 
recovery of vision, as well as increasing the discomfort of the 
sufferer. The pain, if the iris does not become involved, is not 
marked, and the dread of light is perhaps less marked in this, 
than any other disease of the cornea. 

The opacity, on close examination, is found in many cases 
to be of unequal density, or may present a reddish color due 
to the development of blood-vessels in the layers of the cornea. 
This vascularity may involve the whole or only portions of the 
cornea, and may be regarded as an indication of a more serious 
attack than when absent. 

Prognosis. — The duration of the attack is prolonged from 
six months to two years, and when the diagnosis is made, the 
parents of the child should be informed of the probable time to 
be consumed in the development of the various stages, and 
that the ultimate recovery is reasonably sure. While the prog- 
nosis as regards the vision is good, the cornea rarely recovers 
its perfect transparency. Relapses are not infrequent, and com- 
plications of the iris, choroid, retina and glaucoma may occur, 
rendering the prognosis more grave. 

Treatment. — Homeopathic remedies have the power, when 
properly used, to lessen not only the severity of the attack 
and mitigate its symptoms, but also to shorten its duration 
in a remarkable manner. 

No local applications, except that of atropine in cases of iritic 
complications, or the occasional use of cocaine for temporary an- 
esthetic purposes, are advisable, as indeed all others are harm- 
ful. In rare cases hot compresses may be of value, but should 
only be applied under skillful direction. 

As these patients are often anaemic or present indications of 
impaired nutrition, particular attention must be given to proper 
feeding or necessary stimulation. 

The indications for the remedies should be carefully studied; 
these given here constitute the ones more frequently needed. 



OPACITIES OF THE CORNEA. 93 

REMEDIES. 

Auriim Miir. — This preparation is one of the most frequently 
indicated in cases of syphiHtic keratitis. The symptoms are 
those of diffuse infiltration with moderate photophobia, and 
pain which is of a dull character and referred to the parts about 
the eye. 

Mcrcurius Sol. — The inflammation is more active ; there is 
usually more pain, greater ciliary injection and nocturnal ag- 
gravation than under aurum, and the general concomitants of 
mercury are present. 

Mcrcurius Prot. — Often useful when mere. sol. does not act 
promptly. 

Arsenicum. — Diffuse keratitis with marginal vascularity. The 
photophobia is intense, the lachrymation profuse, and burning 
pains are complained of. The aggravation after midnight, rest- 
lessness and thirst are commonly present. 

Apis Mel. — With the infiltration of the cornea there is mod- 
erate injection of the ciliary region and photophobia. Febrile 
disturbance, thirst, and drowsiness often accompany the con- 
dition, 

Hepar Sulphur. — Often serviceable when there is much ciliary 
injection or pain, great photophobia, lachrymation and sensi- 
tiveness of the eye to the touch. 

Baryta lod. — When enlargement of the cervical glands, which 
are hard and painful on pressure, accompany the diseases of the 
cornea. 

Kali Mur. — Interstitial keratitis with occasional pain, mod- 
erate photophobia and redness. 

Opacities of the Cornea, resulting from the various in- 
flammatory affections of the cornea, are termed leucoma, ma- 
cula, and nebula according to the density of the scar, the former 
being the most dense. When their location is not central the 
vision may not be affected, but when located over the pupil the 
vision is destroyed in proportion tothe thickness of the opacity. 

In children the prospect of gradual absorption is good, but it 
is rare that the vision becomes as good as it was before the af- 
fection, which caused its appearance, occurred. The lessening 
of the opacity as the child grows older lessens the cosmetic de- 
fect of the eye, even if the vision is not impaired. When these 
opacities are central and occur in both eyes, they give rise to 
nystagmus, that oscillating, restless movement of the eyes 
which occurs when, owing to the impairment of its central vision, 
the child endeavors to fix the eyes upon the object so that a 
better image may be obtained through the more transparent 



94 THE DISEASES OF CHILDREN. 

portions of the cornea. In cases where it is bilateral, diver- 
gent squint occurs, or when unilateral it may be a cause of 
convergent squint. 

The treatment consists of the use of such homeopathic reme- 
dies as hepar sulph., calc. carb., silicea and sulphur, which in 
some cases exhibit a marked influence in occasioning rapidity 
of tissue change after inflammatory processes. In addition cer- 
tain drugs, which, when applied to the scar, occasion a tempo- 
rary congestion or mild inflammation and hasten its clearing, 
mere, nit., boracic acid powder, sulphate of soda or resorcin, 
when applied by means of a small swab of cotton, giving the 
best results. 

When both eyes present a central opacity, or the vision only 
resides in the one affected by the scar, a new pupil should be 
formed by making an iridectomy in the direction of the most 
transparent portion of the cornea remaining. 

When in older children or adults the leucoma is a source of 
great disfigurement, it may be tattooed with india ink. 

Staphyloma of the cornea, a bulging projection of the cor- 
nea which occurs frequently in children, results from either 
perforation of the cornea and prolapse of the iris following ul- 
ceration in purulent forms of conjunctivitis, or from the soften- 
ing of the corneal tissue which accompanies some cases of 
chronic phlyctenular inflammations with increased fluid pres- 
sure within the eye. 

If the bulging involves the whole of the cornea, it is apt to 
continue until it becomes a serious deformity and protrudes 
between the lids, notwithstanding our efforts to lessen the ten- 
sion by frequent tappings of the anterior chamber (paracentesis 
corneae), or the removal of a portion of the iris (iridectomy). 
When it is complete, and subjected to irritation, inflammation 
of the ball occurs and it becomes necessary to remove the 
projecting portion (abscission) or remove the eyeball (enucle- 
ation). 

Blepharitis Marginalis (ophthalmia tarsi, tinea tarsi, 
acne ciliaris, blepharo adenitis), the free margins of the eyelids 
containing the meibomian glands, the cilia, sebaceous and 
modified perspiratory glands are liable to acute and chronic in- 
flammation in infancy and childhood. With the terminal cir- 
culation of the blood supply at their borders, the high develop- 
ment of glandular structure within them and transition from 
skin to mucous membrane which occurs at their movable edges, 
are presented anatomical conditions which may readily acquire 
a pathological state by inflammatory changes due to heredity, 



BLEPHARITIS MARGINALIS. 95 

impoverished blood, external irritation, or reflex eye strain due 
to errors of refraction. 

Various types of the disease may be described and the dis- 
ease may affect both lids of the eyes, or only a single lid or 
part of it. 

In the more simple cases an incrustation about the base of 
the cilia, resulting in a pyramidical or conical formation from 
an increased secretion from the sebaceous glands at the roots 
of the eyelashes presents the condition which is distinguished 
often by the laity as ''granular lids," a misnomer always. 

Some cases may present only a superficial eczema, character- 
ized by slight redness, with dry or moist scales which form 
upon the lid-edges, but do not form masses clinging to the eye- 
lashes, as in the former type. These types may soon lose the 
simplicity by the lid-border becoming red, the glands and eye- 
lash follicles inflaming and the lid-margin thickening, yellow 
points due to purulent infiltration present themselves, ulcera- 
tion more or less deep of the lid-margins follows. The chronic 
process set up in the appendages of the eye, results in the loss 
of the cilia, the destruction of the lid-margins or their deform- 
ity. The cosmetic defect produced by the ravages of this dis- 
ease is perhaps more readily noticed than that of diseases of 
the eyeball which destroy its beauty or the function of sight. 

Etiology. — This affection of the eyelids begins often early 
in childhood and infancy, and is due either to heredity, malnu- 
trition, or follows as a sequela of the eruptive fevers, of the 
latter, measles perhaps furnishing more commonly the excit- 
ing cause. Chronic catarrhal affections of the conjunctiva and 
lachrymal sac both cause and complicate this disease. Bad 
hygienic surroundings, the exposure to wind, dust, impure at- 
mosphere, as in crowded tenements, should also be mentioned 
as exciting causes. 

Treatment. — In both the simple and severe cases the local 
treatment demands the removal of the masses which form upon 
the cilia, which while they remain, tend to increase by their 
irritation the inflammation of the lids. This is not so readily 
done as might be supposed, as the crusts thus formed are hard, 
not readily soluble, and their mechanical removal often pain- 
ful, and particularly so when the eyelashes are removed with 
them. 

For the removal of these masses the lids should be bathed 
in warm water in which a little bicarbonate of soda or borax 
has been dissolved, and as soon as the crusts have been mois- 
tened they are removed by drawing the cilia through the thumb 
and forefinger, or picked from the lashes by the aid of a pair of 
forceps. These crusts once thoroughly removed, the free mar- 



96 THE DISEASES OF CHILDREN. 

gins of the lids should be smeared with vaseline or cosmoline 
in their plain forms, or in combination with mercury or graph- 
ites in the form of an ointment. The use of these prepara- 
tions hastens the recovery by lessening the irritation of the 
inflamed lid, and by their specific remedial effect when thus 
applied. The effort should be made to have the accumulations 
upon the lid-edges removed as rapidly as they form to prevent 
the increased irritation caused by their presence. 

When blepharitis does not respond promptly to treatment, 
the refraction of the eye must be examined, and when found 
affected, glasses which properly correct the ametropia must be 
worn constantly. 

Occasionally the presence of lice {Phthiriasis ciliarum) upon 
the lashes simulates blepharitis or causes it. The lice are to 
be picked off, the nit which clings to the cilia destroyed, and 
the lid-margins anointed with mercurial ointment to prevent 
their redevelopment. 

REMEDIES. 

Aconite. — Indicated in an acute attack, but such cases are 
extremely rare, and when occurring, result from exposure of 
the eyes to dry cold winds during long drives. The lid-margins 
are swollen, hot and dry, and there is more or less inflamma- 
tion of the conjunctiva accompanying it. 

GrapJiites. — The action upon the edges of the lid is very 
marked, and is perhaps the most useful remedy we possess for 
the chronic form of blepharitis, particularly when occurring in 
strumous subjects and accompanied by the moist, fissured and 
easily bleeding, eczematous eruptions on the cheeks or behind 
the ears, which are so promptly cured by this remedy. The 
swelling of the margins of the lids is variable, in color pale red, 
and crusted with dry scabs which cover spots of ulceration, or 
numerous fine scales are found on the skin and among the cilia, 
which can be brushed off. There is much itching, burning and 
biting of the lids which the patient tries to relieve by rubbing, 
but this only aggravates the trouble. In many cases there is a 
fissured condition of the skin of the outer canthus, which bleeds 
readily from rubbing or opening the eyelids. The cure is 
hastened by the application of the graphites ointment to the 
lids at night. 

Mcrairius. — The various forms of mercury are extremely 
useful in blepharitis, the mere. sol. or vivus more frequently 
perhaps than the others. The lids are much thickened, red, 
and often ulcerated, with sensitiveness to touch, heat and cold. 
The lid conjunctiva is hyperemic, or inflamed, with an acrid 
lachrymation which increases the irritation of the lids. There 



BLEPHARITIS MARGINALIS— REMEDIES. 97 

is an aggravation of the whole condition from exposure to 
the light and heat of fires, or in the evening from artificial 
light. The local application of an ointment containing grs. ii 
of the mere, precip. alb. or the mere. iod. flav. to i3 of vaseline 
will be found very useful. 

Merc. cor. and prot. present similar symptoms, but in a more 
marked degree and where there is a pustular eruption on the 
parts about the eye or upon the conjunctiva. The prescription 
must be based upon a careful consideration of the circum- 
stances and symptoms as well. 

Sulphur. — Suitable in a large number of cases occurring in 
scrofulous children where the disease is occasioned by the 
debility following the exanthematous diseases, or appears as the 
accompaniment of eczema of the face or head, for which sul- 
phur would be indicated. The lids are red, swollen, with nu- 
merous small points of suppuration, or are ulcerated along the 
edges. The characteristic pains are fine, sharp and sticking, 
though itching, biting, burning and many other sensations may 
be present. There is usually an aggravation from wet applica- 
tions to the parts as well as a general aversion to being washed. 

Pulsatilla. — In cases arising from some gastric derangement 
dependent upon consumption of fat foods, there is a great 
tendency to the formation of styes, and frequently acne of the 
face. The swelling and redness of the lids may vary, though 
there is usually a rather profuse, bland discharge which agglu- 
tinates the lids during the night. Itching and burning are 
complained of, with a general evening aggravation and from a 
close or warm atmosphere, with relief from fresh cold air. 

Arsenicum. — Blepharitis occurring in cases where the general 
condition presents debility, restlessness, thirst, night aggrava- 
tion, etc. The lids are often puffed and their edges very red, 
and excoriated by the acrid lachrymation which is a fre- 
quent accompaniment of the condition ; again the lids may be 
smooth, red, and shed numerous scales. The pains are burning 
in character. 

Calc. Carb. — Especially adapted to blepharitis in fat, unhealthy 
children who sweat much about the head. The lids are swollen, 
edematous and red, with a thick, excoriating, purulent dis- 
charge, accompanied by great itching and burning of the lid- 
margins, particularly at the canthi, with aggravation from damp 
weather and in the morning. 

Calc. Phos. and Iod. are serviceable in strumous cases pre- 
senting enlargement of the tonsils and cervical glands, with the 
eye symptoms of the carbonate. 

Hepar Sulph. — The lid-margins are studded with small ulcers 
which destroy the lid tissue ; or they are thick, inflamed and 
D. C.-7 



98 THE DISEASES OF CHILDREN. 

tender to touch, with small furunculous swellings along the 
margins or in the meibomian glands ; eczematous condition of 
the face or outer canthus of the lid with cracking and bleeding 
on opening the eyes. (Compare graphites.) 

Petroleum. — Indicated in affections of the lid when there is 
itching and dryness, with smarting and sticking pains in inner 
canthus. The skin of the lid is often rough and dry, and 
frequently accompanied by the occipital headache character- 
istic of petroleum. The external application of vaseline or 
cosmoline softens the skin and prevents the rapid formation 
of the crusts and the gluing together of the lids, and thus by 
giving relief from this annoyance exerts a beneficial influence. 

A^itim Crud. — Curative in cases occurring in children where 
graphites seems indicated, but when administered gives no re- 
sult. The lids are inflamed, swollen, moist, and there is a 
pustular eruption upon the lids or upon the face, with frequent 
agglutination and photophobia in the morning. 

Natrum Miir. — Useful where the lids are inflamed and 
thickened, accompanied by smarting and burning, with some 
conjunctival inflammation and a sensation of sand in the eyes. 
The lachrymation is acrid and excoriates the lids and cheek, 
giving them the characteristic glossy appearance. 

Rhus Tox. — Suitable in some cases where there is heaviness 
and stiffness of the lids, or an edematous condition with pro- 
fuse lachrymation. 

Sepia. — Scaly conditions of the lids, or small points of pus- 
tular inflammation at the roots of the cilia, with a sensation as 
if the lids pressed too hard on the eyeball. 

Staphisagria. — Lids with dry, uneven margins or hard nodules, 
and much itching and sensation of dryness of the eyes in the 
morning. 

Argentum nit., euphrasia, antim. tart, and mere. nit. may be 
indicated in cases dependent upon, or associated with, con- 
junctival disease ; other medicines may reheve when indicated 
by the general symptoms of the remedy without special refer- 
ence to the eye symptoms. 

Hordeolum, or stye, is an acute inflammation of the cellular 
tissue of the free border of the lid, and appears close to or in- 
volves one or more cilia. At first a small red and hard swelling, 
very painful to touch, it soon causes much inflammation and 
swelling of the part of the lid in which it is located or of the 
entire lid. It becomes developed in three or four days, on its 
summit a yellowish point appears which usually ruptures and 
gives exit to a little pus or necrosed cellular tissue. 

It is very apt to recur, and children suffer from their reap- 



CHALAZION— LACIIRl'M A L DISEASES. 90 

pearance singly or in groups for weeks and months. The 
attacks are due to either such causes as general debility, indis- 
creet diet or the more local one of eye strain dependent upon 
errors of refraction, and irritation of the lids from various 
causes. 

The effort to abort the stye is rarely successful ; as soon as 
it is well underway hot compresses are to be applied to hasten 
the formation of pus, which may be evacuated by a slight in- 
cision or left to break itself. 

Pulsatilla, hepar sulph., or mercurius at times prevent the ex- 
tension of the inflammation, but more frequently shorten the 
course of the attack and hasten resolution. Graphites, sulphur, 
calc. carb., staphisagria and other remedies, when indicated by 
the general symptoms, may prevent the recurrence of the styes. 

Chalazion is a small, firm, immovable tumor, hemispherical 
in shape, which develops in the tarsus and arises from closure 
of the opening of a meibomian gland and the alteration of its 
normal secretion. When it is of spontaneous origin it usually 
disappears in a few days without treatment ; when, as is usually 
the case, its growth is slow, its absorption requires time. In 
children the causes which determine their development are de- 
fective nutrition, the accidental closure of the mouth of one 
of the ducts or inflammation or irritation of the lid-margin. 

The development of the tumor may stop at any stage and 
remain stationary for an indefinite time, its size varying from 
a large pin's head to that of a large pea, rarely developing be- 
yond this point. 

The only disturbance arising from it, except the unsightly 
appearance given by it to the lid, is the slight pressure or rub- 
bing of the eyeball by its internal projection. 

In the majority of cases occurring in children they are ab- 
sorbed without operation, but when necessary maybe removed 
by an incision preferably upon the conjunctival surface of the 
lid and the scooping out of the contents of the cyst. 

Lachrymal diseases are ordinarily rare to the physician, 
but less so to the oculist ; but cases due to arrested develop- 
ment resulting in absence of the lachrymal ducts are not un- 
common. The overflow of tears which may be noticed sooner 
or later by the mother or attendants of the infant indicates the 
fact that the conduits have not been developed or that the nasal 
portion has not been delivered of its fetal debris. If such is 
the case, suppuration of the lachrymal sac of one or both sides 
takes place in the infant, and its subjective redness, swelling, 
and the pain as evinced by the child's restless discomfort indi- 



100 THE DISEASES OF CHILDREN. 

cate to us the location of the lesion, which may require surgical 
interference in the way of incision to relieve the pressure aris- 
ing from the retention of pus. At times the condition is more 
chronic, and with the prescription of the proper homeopathic 
remedy and perhaps the additional aid of some local astringent, 
or a lotion of the remedy indicated for internal prescription 
will often, when the punctum of the canaliculus is not occluded 
or contracted, result in the disappearance of the trouble. 

When the sac or duct is congenitally absent or has been de- 
stroyed by injury, no relief can be obtained for the persistent 
overflow of tears which becomes more marked and annoying as 
the child's years increase. 

If the closure or contraction of the punctum is the fault, then 
it must be opened and attention given to the local inflamma- 
tion of the conjunctiva resulting from the retention in the con- 
junctival sac, of the secretions which should have passed into 
the nose. 

When this has been done and no relief given, ample investi- 
gation of the patency of the nasal duct should follow, and the 
problem of trying to imitate nature's intention by the forma- 
tion of a new opening into the nose is to be considered. In 
view of the necessity, the latter is more frequently accom- 
plished and often is followed by a satisfactory result for the time, 
but the ultimate effect is not to the benefit of the growing 
infant. 

What, then, is to be done when the judgment which should 
come from experience determines an operation not advisable in 
the individual case? Before mutilating the child it may be 
well to assist nature to do the work so well undertaken, but yet 
not completed, and by milder measures enable the child to en- 
joy that comfort which with harsher methods it could not. 

With the aid of cocaine we can in some cases, by the use of 
fine probes, frequently and gently passed to the bottom of the 
sac, stimulate its development, and finally obtain a canal of suf- 
ficient calibre to enable the passage of the secretions from the 
eye, which may increase in size with the facial development of 
the child. 

The treatment consists in removing the discharge which ac- 
cumulates at the inner corner of the eye and the use of a mild 
eye lotion, as that of borax and boracic acid (grs. x. aa to /^gi.), 
which lessens the irritation arising from the retention of the 
lachrymal secretions, and tends to improve the septic condition 
and thus prevent the extension of the inflammation to the con- 
junctiva of the lids and eyeball. After the eye has been thor- 
oughly cleansed, some mild astringent solution may be either 
dropped into the eye or used in a lachrymal syringe, when the 



LACHRYMAL DISEASES— REMEDIES. 101 

lotion may be thrown directly into the sac and forced through 
the nasal duct into the nose. 

The internal medication consists in the use of such reme- 
dies as : 

Aconite. — Indicated when the mucous membrane presents 
the same hypertrophied condition which was present in the 
conjunctival affection which precedes or accompanies it. 

Euphrasia. — Indicated in similar conditions to aconite and 
frequently follows the latter when the discharge becomes thick, 
yellow and acrid. 

Pulsatilla and Calc. Carb. — When there is a profuse, thick 
and bland discharge, the concomitants deciding the choice. 

Argent Nit. — Catarrh of the lachrymal sac, when the dis- 
charge is profuse and the caruncle and semi-lunar folds appear 
red and inflamed. 

Petroleum. — This remedy has a marked action upon the 
mucous membrane of the lachrymal sac when the obstruction 
is due to thickening of the mucous folds. The temporary 
stricture is often relieved by it without the necessity of opera- 
tive interference. 

Caleytdula. — Particularly useful in obstinate cases, when the 
blennorrhoea continues after the duct has been opened, and 
the stricture tends to re-form, and should be applied locally, as 
well as given internally. 

Stanniim. — Relieves some cases of blennorrhoea of the sac, 
where there is a profuse, yellowish-white discharge with sharp 
pain or itching of the inner canthus, particularly at night. 

Arsen. lod. — Proves useful in curing obstructions of the duct 
dependent upon acute inflammation and swelling of the nasal 
mucous membrane. It may be suitable in those cases of blen- 
norrhoea of the duct accompanied by a dry ulcerated condition 
of the nostrils. 

Hepar Sulph. — In inflammatory conditions of the sac with 
sensitiveness to touch, and free discharge of pus with or with- 
out an opened canaliculus. 

Mercurius. — The discharge is thin, acrid, and often excor- 
iates the lid-margins, or the cheek where the overflow comes 
in contact with it. 

Silicea. — There is a bland, whitish discharge of decomposed 
mucus and pus from the distended sac after the canaliculus 
has been opened and probing begun. It may be also indicated 
in the recurrent inflammatory attacks of old cases of blennor- 
rhoea of the sac. 

Many other remedies have been recommended and have un- 
doubtedly been of service in improving the condition, as arum 
tr., aurum mur., belladonna, calc. carb., cuprum alumina, hy- 



102 THE DISEASES OF CHILDREN. 

drastis, fluor. ac, kali iod., natrum mur., nux vomica, sulphur 
and zinc, sulph. 

Strabismus (squint or cross-eye) is a deviation of one of the 
eyes when looking at an object, owing to the inability of the 
child or individual to bring the eyes to bear upon the object so 
that the visual axes meet at the point of the object looked at. 
In the normal state of the eye muscles, when any object is 
looked at, the visual axes of both eyes are directed to the same 
point of the object. When squint is present, both eyes are not 
equally turned, one eye being directed toward the object, while 
the imaginary line of the visual axis of the other, passes to one 
side or the other of the object, and the squinting eye turns 
inward (strabismus convergens), or outward (strabismus diver- 
gens), or upward (strabismus deorsum vergens), or downward 
(strabismus sursum vergens). 

The six muscles of each eye which enable the eyes to assume 
their varied positions, are, when normal, so evenly balanced, 
that all motions of the eye in their associated movements are 
in perfect co-ordination, and the visual axes meet at the object 
to which the eyes are directed. When from any cause, one or 
more muscles present an excess, or a lack of innervation, a dis- 
turbance of the normal equilibrium occurs. In the associated 
action of the eyes there is a deviation from their proper direc- 
tion in looking at an object, and the deviating or squinting eye 
takes the direction of the strongest muscle. 

Strabismus is an objective symptom arising from various 
causes. If it occurs in acute illness it is a grave prognostic. 
It may occur as a reflex of the stomach and intestines, from 
worms, or other scources of local irritation or inflammation; 
from meningeal and cerebral lesions, which may cause tonic 
spasm and paralysis of certain of the eye muscles. 

In the convulsions of infancy, squint is often a symptom 
which becomes permanent, or afterwards disappears. When 
the eye becomes crossed in the course of tubercular meningitis, 
it is a symptom of approaching death. Whooping cough, 
measles, scarlet fever, diphtheria and other diseases of child- 
hood are fruitful causes of strabismus, owing to the enfeeble- 
ment of one or more of the eye muscles during or following 
the disease, and a consequent disturbance of the balance of the 
relative powers of the muscles. An eye in infancy or child- 
hood during its exclusion from light and the associated visual 
acts of its fellow, owing to the bandaging which may be neces- 
sary for its restoration to health, is not infrequently found to 
turn inward or outward when recovery from the inflammation 
or ulceration is complete. When the vision has been partially 



5 TRA BISM I 'S— TREA TMEN T. 1 03 

lost as a result of such inflammations, the squint may appear at 
a later period. Various other causes are assigned by the par- 
ents for its production, but their etiological value are too often 
impossible for the ophthalmic surgeon to determine. Squint 
rarely exists at birth and is developed usually as the result of 
the close approximation of the infant's near-point and its effort 
to observe objects attentively. At first it may only be ob- 
served occasionally (periodic strabismus), or noticed perhaps in 
one eye and again in the other (alternating strabismus), or later 
becomes a permanent squint of one or both eyes. 

The common cause of this deformity is that which arises 
from the imperfect development of the optical apparatus, the 
power of accommodation or other defects which affect the recep- 
tion and transmission of the objects looked at. There is still a 
difference of opinion as to the origin of the strabismus and the 
loss of vision which occurs in the squinting eye. 

That there is either an early innervation of the muscles, an 
ametropic condition of the refraction, or a loss of central vision 
in many cases, all agree. The question as to the cause of loss 
of vision in the squinting eye, whether due to the suppression 
of the image (amblyopia exanopsia), or defects of the retinal 
function still remains undetermined. 

Treatjnent. — When strabismus still persists after the acute 
disease which may have produced it has passed, and the devia- 
tion is due to paralysis of the opposing muscle, attention should 
be directed to the improvement of innervation of the paretic 
muscle by galvanism and such remedies as may be indicated 
by the concomitant symptoms. 

As the common cause of non-paralytic squint is either a nat- 
ural preponderance of the internal recti muscles over the ex- 
ternal or a hypermetropic or other defective conditions of the 
refraction with their increased demands for convergence, we 
have first to correct the ametropic refraction with properly ad- 
justed glasses. This is usually impracticable under four years of 
age, as while it is possible to determine gross errors of refraction 
in young children with the ophthalmoscope, the use of glasses 
thus prescribed are usually of no value and certainly in the ma- 
jority of cases a matter of great anxiety to the parent or attend- 
ant of the child. Bandaging the non-squinting eye for stated 
periods each day, or the use of atropia to paralyze the accommo- 
dation continually or daily exercise of the muscles by prisms 
afford much better results in the majority of cases in very 
young children. With increased age, the development of the 
nose-bridge and the medial sinuses, by increasing the pupillary 
distance causes a disappearance of many convergent squints. 
The development of the eye, and its muscles accompanying 



104 THE DISEASES OF CHILDREN. 

that of the head and face results in an ability to co-ordinate the 
muscles properly. In all cases special attention should be given 
to improve the general nutrition which is too often at fault. 
When, however, by the use of such remedies as gels., arg. 
nit., cicuta, cina, belladonna, hyoscyamus, jaborandi, spigelia 
and santonine, which may be indicated, both by their direct 
action upon the muscles at fault or when such other measures 
as those already stated have been of no avail, it is necessary to 
make a tenotomy of the muscle which exhibits the greater over- 
action. When the operation should be done, and its extent^ 
can only be determined by the ophthalmic surgeon, when he 
has assured himself that all else has been done for its non-sur- 
gical cure. In the event of an operation, in young children 
particularly, it is well to do too little rather than too much, as 
the full correction or over-correction is not always apparent 
until some months have passed. The operation is made ordi- 
narily for its cosmetic effect, as in the majority of cases the 
vision of the squinting eye is not recovered as a result of the 
operation and should not be expected, nor should the glasses 
which have been used to correct the ametropia, be expected to 
be discontinued, as the tenotomy which has corrected the devi- 
ation has not removed the refractive error which still persists 
as an active cause and tends to reproduce the squint. For the 
technique of the operation reference should be made to special 
works upon the eye. 

When the strabismus is due to paralysis, operative measures 
are not to be undertaken until all possible chances of recovery 
have passed, and then not with the expectation that anything 
can be accomplished except to lessen the cosmetic defect. 

Heterophoria, is a term given by Dr. S. T. Stevens, of 
New York, to a disturbance of the equilibrium of the eye mus- 
cles, and is a condition which, while formerly considered under 
the term muscular insufficiency, has, owing to his investigations, 
become a condition of greater importance as regards its deter- 
mination and the effect upon the use of the eyes and those 
reflex conditions which may follow certain derangements of 
the eye muscles. In general explanation it may be said if the 
eye muscles are of normal equilibrium, orthophoria is present ; 
if this equilibrium is disturbed, then heterophoria is present ; 
the visual lines in the former being parallel, while the latter, 
owing to muscular insufficiency, tend, as in strabismus, to de- 
viate. The heterophorias are subdivided into esophoria, when 
the visual lines tend inward (insufficiency of the external recti); 
exophoria, when they tend outward (insufficiency of internal 
recti); and hyperphoria, when that of either eye tends upward. 



THE USE OF GLASSES. 10.") 

The determination and measure of these muscular deficien- 
cies is accomplished by the use of prisms, which are succes- 
sively placed before the eye whose muscles' strength is under 
examination, both eyes being directed upon a candle or other 
source of illumination at a distance of twenty feet, the thin 
edge of the prism being placed in the direction of the muscle 
under examination. The degree of the strongest prism thus 
used, which still enables the individual to maintain single vision, 
gives the strength of the muscle tested, and is to be compared 
with approximate standard for that muscle. Various modifi- 
cations of this simple test are often necessary to determine the 
individual loss of equilibrium which may exist, and it should 
be borne in mind that all such values are only relative. 

The causes of the heterophoria are those arising from mal- 
nutrition, rapid growth, innervations incident to approaching 
puberty, eye strain dependent upon errors of refraction, and 
depressions of the muscular and nervous systems accompany- 
ing or following exhausting diseases. 

The presence of these insufficiencies of the ocular muscles 
are undoubtedly the cause of much discomfort to children in 
the use of their eyes, headache, and perhaps more neurotic 
symptoms, as chorea and epilepsy. It should be said, however, 
that they are more frequently the reflex of disturbance of re- 
mote organs, than they are cause of the many affections attrib- 
uted to them. 

The treatment consists primarily in the correction of the nu- 
trition ; correction of the optical defects by the use of glasses ; 
the regulation of the use of the eyes; proper exercise and good 
hygiene ; the methodic exercise of the eye muscles by means 
of prisms, and in the failure of these, a graduated tenotomy of 
the stronger muscle may be made, but always with the greatest 
of care, and when only there seems no chance for natural 
recovery of this weakened power of the muscle in the child. 

The Use of Glasses.— Amatus and Friar Bacon discovered 
during the thirteenth century, that a bit of glass with a convex 
surface, when placed before their eyes, enabled them again to 
see with eyes that had become dimmed by the changes inci- 
dent to their advancing age. This invention and its practical 
application has been of inestimable advantage to the world ; 
improving sight at all ages, lessening the number of the blind, 
lengthening the days of the aged, advancing civilization and 
making the world brighter and better for all. 

The question is often asked, Why do so many children wear 
glasses now-a-days? The frequency with which one now meets 
children of all ages wearing lenses is rather startling to the 



106 THE DISEASES OF CHILDREN. 

many who do not appreciate the possible needs which require 
their use nor know of the good which is accompHshed by them. 

As the child passes from infancy to childhood, defects and 
disturbances, before unnoticed, now become fully recognized as 
the child attains an age when it can communicate them. Again, 
as it begins also to exercise the visual function more closely 
and for a longer time, this is particularly true of those children 
who are placed in kindergartens, where the character of some 
of the work to which they are put is such as to strain the eyes 
of those much older and stronger. While the work itself does 
not cause the defects of vision or muscular insufficiencies 
which we frequently find to be present, it does bring out these 
defects at an earlier age than under other circumstances. When 
children begin to use their eyes intelligently upon the objects 
around them, an inquiry should be made into the power and 
extent of the visual function. It is an error for the parent to 
consider that the child must have, by reason of its birth, eyes 
of the same formation, visual power and endurance as his own. 
The examination of many thousands of children's eyes exhibits 
the fact that the proportion of normal eyes is only about 1 1 
per cent. ; the balance exhibiting various refractive errors, as 
hyperopia, myopia and astigmatism in the order given. The 
presence of these defects interferes both with the vision and also 
with normal and comfortable use of the eyes. In the efTort to 
see, the child is compelled to exercise an undue amount of 
force in trying to overcome the defect. The continued effort 
thus needed results in a rapid exhaustion of that reserve energy 
which is needed for the maintenance of the normal equilibrium 
of the general nervous system. Complaint is made of the 
vision and the eyes, the head suffers, various reflex nervous 
symptoms are excited and the condition presents a serious 
aspect. 

The confinement of the child to the too often impure air of 
the school room, the forcing process common to our school 
system of to-day, the method of education by means of the 
eye in which learning is acquired by writing, all tend to weaken 
both the child's physical condition and the eyes as well. 

With the acquirement of exact knowledge of the eye condition, 
its various defects and needs, the ophthalmic surgeon finds that 
the correction of the errors of refraction by properly adjusted 
glasses results in a restoration of the vision, relief of the eye 
strain, improvement of the disposition of the child, in the dis- 
appearance of many obscure nervous symptoms which were 
undoubtedly reflex, and sometimes the cure of an apparent 
idiocy due to mental deficiency. 

The use of glasses at an early age also enables the vision to 



GENERAL DISEASES— CA USA TIVE RE LA TION. 307 

be retained in many cases which otherwise would be bhnd 
before puberty ; again by their use the imperfectly developed 
eye may be stimulated to such an extent as to acquire during 
the early years of life a more nearly normal condition. In all 
cases where glasses may be indicated the greatest care should 
be exercised in their selection and adaptation to each individual 
case, as, when not properly prescribed, they are as capable of 
injury as those which suit the condition are of good. 

SYSTEMIC AND GENERAL DISEASES IN THEIR CAUSATIVE RE- 
LATION TO EYE DISEASES IN CHILDHOOD. 

Intestinal Diseases, when of an exhausting nature, may pre- 
sent such eye complications as ulceration or abscess of the 
cornea which threaten to destroy the vision and are at the 
same time usually prognostic of approaching death. Intestinal 
irritation due to parasites or other causes frequently pro- 
duces marked affections of the eyes, such as temporary blind- 
ness, attacks of weak vision, photophobia, unequal dilatation 
of the pupils, strabismus, morbid nictitation or nystagmus. 

Dentition. — During the eruption of the teeth the eyes ex- 
hibit a tendency to exacerbation of any existing eye inflamma- 
tion and the development of such affections as blepharitis 
marginalis, phlyctenular inflammation of the cornea and con- 
junctiva, mild attacks of catarrhal conjunctivitis and hyper- 
emia of the conjunctiva with lachrymation. 

Scrofula exhibits usually such superficial affections of the 
eye as inflammation of the lid-margins, phlyctenular inflam- 
mations of the conjunctiva and cornea, which are character- 
ized by tediousness, recurrence, and slowness to respond to 
treatment. 

Syphilis produces a varied and profound effect upon the 
eyes of children as well as adults, and any tissue of the eye 
may suffer from its ravages. Acquired syphilis as a cause of con- 
genital changes in the eye has already been referred to, as well 
as that form of parenchymatous keratitis which appears be- 
tween the ages of two and fifteen years and rarely in after life. 
Inflammation of the iris, choroid and retina during the first 
three or four years of life are not uncommon. Owing to the 
delicacy of the structures involved, the inflammation resulting 
from the dyscrasia, together with the persistent character, 
which marks the attack, the danger to the sight of the child 
becomes very great. 

Rubeola is a prolific cause of certain eye affections. At its 
inception a mild catarrhal conjunctivitis with a more or less 
marked photophobia is usually observed. This condition may 



108 THE DISEASES OF CHILDREN. 

pass rapidly into a muco-purulent conjunctivitis in some cases, 
or even a dangerous purulent ophthalmia of a croupous vari- 
ety may follow and be destructive to the eyes. The greater 
number of eye diseases due to measles, however, appear as 
sequelae and by no means always following immediately after 
the attack of the eruptive fever. It would seem, from the 
great variety of eye affections which are traceable to rubeola, 
that no other disease of childhood presents so great a number 
of eyes of impaired vision or function. Undoubtedly the 
poisonous effect of the exanthem in perverting the nutrition 
of children already predisposed to malnutrition from various 
causes, accounts for the development of various diseases of the 
lids, cornea and conjunctiva, as well as those functional affec- 
tions of the eye muscles and retina which are so common to 
the oculist. Affections of the optic nerve, such as optic neu- 
ritis, may complicate an attack of measles from retrocession of 
the eruption or follow after. 

Rotheln rarely, if ever, presents any eye complication beyond 
that of a mild conjunctivitis, which usually disappears with the 
recovery of the child from its attack of false measles. 

Scarlatina, while presenting commonly only a transient 
hyperemia of the conjunctiva, with increased lachrymation 
coincident with erythema of the skin, sometimes is complicated 
with a rapid loss of vision ; in one case coming under my obser- 
vation the blindness existed for four days, and was evidently 
due to the toxic effect of the disease upon the blood without 
nephritic complication. Purulent and diphtheritic inflamma- 
tions of the conjunctiva occur only in those desperate and usu- 
ally fatal cases of complicated scarlatina. The sequelae of 
scarlet fever, with the exception of the nephritic and diph- 
theritic complications, exhibit no such tendency to produce eye 
disturbances as does measles. When the eruption is repressed, 
cases of loss of vision have been reported. 

Roseola, varicella or vaccina produce no eye symptoms of 
direct value. 

Variola may destroy vision from ulceration of the cornea ; in 
rare cases, from the formation of a pustule upon the cornea or 
upon its margins. 

Diphtheria rarely affects the eye in childhood, except by di- 
rect inoculation, or from extension from the nose, and when it 
occurs destruction of both sight and eye follows. As the 
child recovers from the systemic disease, it is not uncom- 
mon to find that the power of accommodation for near objects 
has been lost. While the prognosis is usually good in these 
cases, a permanent weakness of the ciliary muscle undoubtedly 
remains in many cases. 



GENERAL DISEASES— CAUSATIVE RELATION. 109 

Pertussis in its convulsive sta^e may cause sudden blindness 
from hemorrhage within the eye, due to rupture of a blood- 
vessel of the choroid during the paroxysm, or in other cases 
from an ischemia of the retina. Spots of effused blood in the 
conjunctiva from rupture of the capillaries are a very frequent 
accompaniment of cough paroxysms. 

Phlyctenular inflammations of the conjunctiva and ulcers of 
the cornea are not infrequent sequelae of this disease. 

Parotitis rarely exhibits any eye complication, although 
cases have occurred where there has been a disturbance of the 
retina with temporary failure of the vision and others present- 
ing a passing effusion in the orbit with paresis of the oculo- 
motor nerve. 

Cerebrospinal Fever may be complicated with ulceration of 
the cornea, hyperemia of the optic disc and retina, or even an 
acute choroiditis, with exudation of lymph in the vitreous and 
blindness result. 

Typhoid Fever seldom occasions any disturbance of the 
eyes except, in low cases, when an ulceration of the cornea 
and impaired vision are due to exhaustion. Optic nerve lesions 
appear as a result of meningeal complications. 

Intermittent Fevers in children show a proneness to eye af- 
fections, both during the course of the fever and also later. 
Iritis, phlyctenules, corneal ulcers, strabismus and heteropho- 
rias, with all their dangers and discomforts, may attend or follow 
an attack of malaria. 

Rheumatism rarely causes any disease of the eye in children 
except in extremely rare cases, when an iritis or a mild scleritis 
may occur. 

Diseases of the Heart, even in children, produce certain 
changes in the eye and disturbance of the visual function, the 
latter coincident with valvular diseases. 

Fx-ophthalmic Goitre, however, is the most common eye dis- 
ease arising from heart complication. It appears in childhood 
only at the approach to puberty or soon after the menstrual 
function has been established. With the enlargement of the 
thyroid and disturbed action of the heart, there is a marked 
prominence of the eyes with a partial retraction of the upper 
eyelids which occasions a peculiar stare characteristic of the 
disease. When occurring in children it is much more readily 
cured when early recognized and treated, than in adults. 

Hydrocephalus causes impairment of the vision either from 
pressure exerted directly upon the optic tracts, or from the dis- 
turbance of the functional activity of the visual centers by the 
distention of the brain cortex. The position of the eyes, as 
they are pushed downward by the pressure upon the roof of 



110 THE DISEASES OF CHILDREN. 

the orbits, gives to the hydrocephalic child a fixed stare which 
is unique. In the early stages of the disease strabismus or 
nystagmus may be observed. 

Diseases of the Central Nervous System, particularly those 
of gross character, such as tumors of the brain, rarely find 
expression in the eyes of children unless due to inherited 
syphilis, when, as in the adult, optic neuritis may occur before 
death. 

Meningitis, however, presents not only the paralysis of the 
ocular muscles, but when the inflammation involves the base 
of the brain, optic neuritis and consequent atrophy are not 
uncommon. 

Diseases of the Sexual System afford many cases of dis- 
turbances of the eye relation prior to and at the time of pu- 
berty. It is a noticeable fact that a more marked effect is 
produced upon the eyes of girls at this period than those of 
boys. The rapid development of the body which occurs at the 
time of puberty is often preceded by a variety of eye symptoms 
which are often alarming, in that there is frequently a marked 
affection of the vision, a disturbance of the equilibrium of the 
eye muscles from loss of physical tone or occasioned by errors 
of refraction which before have passed unnoticed. The eye 
afTections thus caused become not only causes of discomfort to 
the child, but produce reflex effects of both the head and the 
general nervous system as well. In cases when the headaches, 
chorea and other now remote nervous symptoms do not disap- 
pear when such local causes of irritation as congested ovaries, 
vaginal inflammation, contracted or adherent prepuce, or the 
habit of masturbation have been removed, the eyes should be 
well examined and all refractive errors and muscular defects 
corrected as far as possible, and often with remarkable improve- 
ment in the child's condition. 

The effort of nature to establish the menstrual function in 
the child who has perhaps reached that period of its life when 
it should pass from childhood to girlhood, is not infrequently 
attended by various disorders of the eye which may precede 
the appearance of the menses, accompany them, or remain 
until the function becomes regular. Morbid winking, chorea of 
the eyelids and face, spasm of the lids, asthenopia, heterophoria, 
hysterical loss of vision, neuralgia of the eye, intra-ocular hem- 
orrhages, choriditis, neuro-retinitis and optic neuritis may all 
arise during this too often trying period of the child's existence. 
In the male child abnormal nictitation, conjunctival hyperemias, 
headaches and chorea at puberty are more frequently observed, 
while the deeper eye affections are uncommon. 

Injuries of the Eye i7t Children — Traumatism of the eye 



GENERA L DISEA SES— CA USA TI VE RE LA TION. \\\ 

of the child has, as in adults, the danger to sight or life in 
proportion to its extent and the location of the injury. Upon 
the care given immediately after the accident too often 
depends the recovery or loss of sight. It is impossible to pre- 
sent any single rule for the proper treatment of all the wounds 
and injuries of the eye which, small as the organ is, when the 
accidents to which it may be subjected, are so numerous, so 
frequent, and so dangerous to the delicate organ of sight. No 
matter how long or broad the experience of the ophthalmic 
surgeon may be, each case of injury to the eye presented to 
him may have some variation in cause, location of lesion or effect 
upon the sight, which will require the aid of all his experience 
and skill to avoid destruction of sight or eyeball, and yet be 
compelled to witness the inability of his efforts. 

In young children the retention of foreign bodies upon the 
eyeball or beneath the lids is much more rare than in adults, 
owing to the lax application of the lids to the surface of the 
ball, and also to the more active condition of the lachrymal 
gland, which at this stage of life responds so readily with its 
shower of tears upon irritation of the conjunctiva. When 
foreign bodies remain upon the eyeball or beneath the lid, 
there is apparently less pain referred to the eye than in adults, 
but a watery, congestive appearance of the eye or an inflamma- 
tion of the conjunctiva is presented, and the first duty is to look 
for the cause of the irritation or inflammation which may be 
discovered in an imbedded bit of foreign substance in the cor- 
nea, conjunctiva of the eyeball or lids, the child being less 
likely to complain of the cause of the trouble than the adult. 
A drop or two of a two per. cent, solution of cocaine renders 
the eye sufficiently anesthetic to enable one to examine it 
comfortably to the patient and thoroughly by the attendant, so 
as when its location has been discovered to remove it without 
pain. When not found upon the surface of the globe, the 
upper lid should be everted, when its location will be found 
near the center of the free margin or at the angles of the tar- 
sus. Its removal and the application of a cold compress or the 
instillation of a mild coUyrium is usually sufficient to cause a 
return of the eye to its normal condition in a few hours, unless 
the irritation and inflammation have been excessive. 

The dangerous injuries of the eye from which the child is 
likely to suffer are those of burns and scalds from hot water, 
lime and mortar and hot pokers, punctured wounds arising 
from forks, scissors, pointed sticks or knives. Not infrequently 
the pet dog, cat or monkey have in my experience produced by 
accident or intent a laceration of the lids or eyeball. Contusion 
of the lids or ball from blows or blunt bodies, such as sticks, 



112 THE DISEASES OF CHILDREN. 

balls, pebbles, etc., may cause hemorrhages within the eye, or 
concussion of the eye sufficient to destroy the function of 
sight is not uncommon among older children. In all cases the 
greater danger lies in the effort on the part of the unskilled 
attendant to do too much. The fact that the child makes little 
complaint after injury to the eye is too often misleading, as 
deep injuries to the eyeball, both in children and adults, produce 
an anesthetic condition which is apt to prevent an early and a 
proper recognition of their extent or the danger incident to 
them. 

When foreign bodies or masses of dirt or other extraneous 
substances have found their way upon the ball or beneath the 
lids, the first thing to do is to remove them with a suitable in- 
strument, or by washing or gently syringing the eye with warm 
water after rendering the eye anesthetic by cocaine ; then as- 
certain the extent of the injury and its danger to eyeball and 
sight, and apply cold compresses and such antiseptic coUyrium 
as may be indicated. In cases where penetrating wounds of 
the eyeball have occurred, while they may seem very slight at 
first, their ultimate results may be very grave, and the medical 
attendant can rarely, if ever, err by prescribing a proper solu- 
tion of atropia, according to the age of the child, to dilate the 
pupil, and apply cold compresses of ice to the eye. Efforts to 
determine the extent of the injury by too much examination 
by unskillful hands result in the destruction of eyes which 
might be saved. 

In all extensive injuries of the eyeball, such as great lacera- 
tions or where foreign bodies have been projected within the 
eyeball, the danger of sympathetic inflammation, which may 
destroy the sight of the remaining eye, should always be borne 
in mind. The necessity for the removal of the injured eye to 
prevent total blindness is often indicated ; but in children, 
where, in the absence of a foreign body within the eye, or the 
laceration is not too great, it becomes the duty of the ophthal- 
mic surgeon to consider the effect which the immediate re- 
moval of the eyeball will have upon the development of the 
orbit and the side of the face of the injured eye. In all cases, 
should indications of a sympathetic irritation or inflammation 
supervene in the other, after injury of one eye, no time should 
be lost, when by the removal of the injured eye it may be 
possible to save the sight of its fellow. 

Glioma of the Retma and Optic Nerve, or Fungus He7natodes, 
is usually the only malignant tumor of the eyes of children 
which we may be called upon to consider. It is almost exclu- 
sively a cancer of childhood, occurring usually between the 
ages of one and twelve years ; it may, however, appear as early 



GENERA L DISEA SES— CA USA TI VE REL A TION. 113 

as the second month after birth. It is probably hereditary 
and dependent upon a cancerous dyscrasia. 

The earliest symptom is a whitish-yellow, or bluish-white ap- 
pearance of the pupil, which on examination is found to exist 
behind the lens, and the eye is devoid of vision. No pain or 
redness is present, and often the case is not brought for treat- 
ment until the eye becomes enlarged, or pain and congestion 
of the sclera occur. As the tumor grows it advances into the 
interior of the eyeball, producing atrophy and detachment of 
the retina as it proceeds. With the ophthalmoscope it appears 
like a detachment of the retina or inflammatory changes in the 
vitreous, which closely simulate it, and from which it must be 
distinguished by the absence of iritic adhesion, and from the his- 
tory of the inflammation preceding the white or yellowish ap- 
pearance of the pupil. The appearance of the vessels upon the 
surface of the bulging mass, which do not correspond with those 
of the retina, will enable us to designate it from other affec- 
tions. As the tumor increases in size the intra-ocular tension 
increases, and the pupil becomes dilated and the child com- 
plains of pain from the glaucomatous condition which occurs ; 
other portions of the tissues of the globe become involved 
with the increase of the tumor, and the lens loses its trans- 
parency, the cornea becomes opaque, and all semblance of 
the eyeball is lost in the protruding mass which extrudes 
between the lids and appears as a fleshy body, secreting a 
sanious discharge and subject to frequent hemorrhages in the 
advanced stage of the disease, when it is called fungus hema- 
todes of the eye. 

When the disease is recognized in the early stages, while 
confined to the retina, the removal of the eyeball with a por- 
tion of the optic nerve, which on examination shows no sign 
of implication, is usually favorable. The case, however, is even 
then not safe until several months or a year have passed with- 
out indications of the return of the growth. In the majority 
of cases the removal of the eye is not acceded to, or the disease 
has progressed along the optic nerve so that the brain is often- 
times affected, or the contents of the orbit have become infil- 
trated with cancerous cells, so that death follows at an early 
date, from intra-cranial tumor or exhaustion due to the can- 
cerous cachexia. 

Immediate removal of the ball, with as great a portion of the 
optic nerve as possible, is imperative when the tumor is con- 
fined to the interior of the eye. When it has extended beyond 
the confines of the globe, the question of operative interference 
is a grave one, as often the complete extirpation of the con- 
tents of the orbit affords only temporary relief, the sarcoma- 
D. C— 8 



114 THE DISEASES OF CHILDREN. 

tous mass, under these circumstances, seeming to acquire fresh 
energy from the operative measures. 

In extremely rare cases the growth is reported to have been 
checked and the eyeball becomes atrophied, but this is so 
unusual, and the general tendency of the disease so fatal, that 
time should not be lost in awaiting probable absorption. 
After the removal of the growth, it is my practice to place 
these patients upon carbolic acid ist dec. in water, a dose three 
times a day for several months, and good results have occurred 
from its use. 



CHAPTER II. 

DISEASES OF THE EAR. 

The infant ear at birth rarely receives as much attention as 
the eye, unless an absence of the auricle excites the notice of 
the attendant or some other deformity is apparent. As the 
ear -is not susceptible to those destructive inflammations due to 
inoculation from the abnormal vaginal secretions of the mother 
soon after birth as the eye, it naturally requires less careful 
examination. 

Congenital Malp^ormations are, however, too often pres- 
ent as a result of a partial or complete arrest of development 
in utero, and the auricles may be so rudimentary as to be said to 
be absent on one or both sides. When the auricle is rudiment- 
ary, the external auditory canal may also be absent or be closed 
by a fold of skin, which prevents the passage of sound vibrations 
to the middle ear. When the auricle is congenitally non-de- 
veloped, there is usually some rudimentary evidence of nature's 
effort to complete the work, as is shown by the presence of no- 
dules of skin and cartilage in the vicinity of the site of what 
should have been an auricle. With the non-development of 
the auricle, there is usually associated a similar defect in the 
external auditory meatus and also one of the middle and in- 
ternal ear, so that surgical interference, which might seem indi- 
cated for the purpose of opening the canal, is rarely of any 
value for the relief of the deafness which accompanies the 
defect. 

Various deformities of the external ear may be present as 
congenital defects, such as a malformed auricle, where a high 
degree of hypertrophy is exhibited, or arrest of development 
and an asymmetry of the two ears confront us ; clefts and fis- 
sures of the auricle, when present, or when the angle of its 
insertion may give an abnormal expression to those appen- 
dages, as where the auricles are too closely applied to the 
head or are set at a too advanced angle with the plane of the 
head. Such anomalies, while not necessarily interfering with 
the child's hearing, oftentimes cause in the child, as it advances 
in years, a marked disfigurement, and our efforts toward an im- 
provement of the condition are rarely followed by any gain in 

(115) 



116 THE DISEASES OF CHILDREN, 

esthetic effect. A congenital fistula, situated in the ascending 
portion of the helix of the auricle, the opening leading into a 
blind canal, with a thick, creamy secretion, has been recorded, 
as well as certain fistulas of the canal communicating with the 
middle ear. The external auditory canal is more often the seat 
of congenital abnormalities than that of the auricle, and may ex- 
hibit throughout the whole extent conditions of contraction or 
closure due to cuticular or osseous hypertrophy. With a full de- 
velopment of the auricle and a partial or complete closure of 
the auditory canal, we not infrequently find, after perforation 
of the skin or bone which seemed to intervene between the ex- 
ternal and middle ears, that the canal ends in a cul-de-sac and 
that the middle ear is without proper development ; hence our 
surgical efforts for the correction of such conditions are usually 
without good result. 

Congenital malformations of the drum-membrane, the middle 
ear or the internal ear are rarely noticed in infancy, although 
they may be present. When the child has arrived at a period 
of its existence when its mental development seems to be at 
fault, its speech absent or its hearing in doubt, we often find 
on examination that there are physical defects of the auditory 
apparatus which are sufHcient to explain these deficiencies. 
They are usually not remediable, so that the child, when both 
ears are affected, is a deaf-mute and should be afforded that 
education applicable to the deaf and dumb which is necessary 
to make such children bread-winners and intelligent members 
of the community in which they may reside. 

At birth the external auditory canal is filled with a plug of 
detritus, in which epithelial cells from the epidermis lining it 
are found mixed with the caseous material which covers and 
protects the fetus during its intra-uterine life; the accumulation 
soon after birth dries up and falls out, or later, when attention 
may be called to the infant's ears and the plug found to be still 
there, its removal is to be accomplished by the use of the aural 
syringe. 

The middle ear cavity may also at birth have retained the 
debris incident to its development. This accumulation should 
pass out through the eustachian tube into the throat, leaving 
the middle ear in condition for the conduction of sound; it 
probably does not do so as frequently as is supposed. When 
this condition, is present, its effect is to cause deafness and re- 
tard the hearing perception of the infant, and acting as an irri- 
tant sets up a suppurative inflammation which liquefies the mass, 
so that if the eustachian tube is pervious it passes into the 
throat, or when the latter does not open under the pressure of 
the accumulation, the drum-head ruptures and those early sup- 



CONGENITAL MALFORMATIONS. 117 

purations of the middle ear which occur during the first month 
or two of infantile life are explained. 

The ear of the new-born does not present that completeness 
of development which is found in the eye at the same period. 
The orbits of the eyes exhibit in the infant a much greater de- 
velopment at birth than does the temporal bone in which the 
auditory organ has its location and upon which its develop- 
ment depends. While the eyeballs and their appendages at 
birth, when normal, closely approximate the size and shape of 
those of adult life, the ears present much less advancement in 
the scale of development. 

The temporal bone at the time of birth differs materially 
from that of the adult, and as the essential portions of the hear- 
ing apparatus are inclosed in its structure, the development of 
the ear is in close relation to its ossification, which proceeds 
slowly and yet always within keeping of that development of 
the skull which accompanies the normal physical and mental 
development of the child. 

In the early stages of infancy one looks in vain for an audi- 
tory canal of full length or a drum-head in the position of that of 
adult life. The external auditory canal has at this time of in- 
fantile life only its cartilaginous portion, is short and the osseous 
portion undeveloped ; the drum-membrane, instead of being vis- 
ible as in the adult at an acute angle with the lower wall of the 
canal, is now found almost horizontal with the upper wall. 

The mastoid process, which in the adult temporal bone pre- 
sents a flattened conical mass with apex downward, is only rudi- 
mentary in the infant, and only becomes prominent in a physi- 
ological or pathological sense with the progressive development 
of the temporal bone and that of the child. 

The examination of the drum-membrane in early infancy, to 
determine the value of its presenting condition in connection 
with other symptoms or diseases of the child, is accordingly ac- 
complished only with effort, and variations in its appearance 
when seen are only of diagnostic and prognostic value after many 
accurate observations have been made of other ears by the in- 
dividual examiner. As the infant becomes more developed, its 
aural affections increase in frequency and extent and the diag- 
nostic value of the examination of its ears of greater impor- 
tance, not only in determining the local affection, but also elim- 
inating the ear as a possible cause or complication, as well as 
presenting often a prognostic indication as well as an aid to 
rational treatment. 

The 'examination of the ears should always be conducted 
under such circumstances as enable one to see the condition of 
the meatus and drum-head ; the instruments necessary are a 



118 THE DISEASES OF CHILDREN. 

speculum to dilate and straighten the canal, and a mirror re- 
flecting sufficient light to illuminate the meatus and drum- 
membrane. The view thus obtained, together with a knowledge 
of the value of the variations from the normal appearance of 
these parts when presented, aid us to give a greater certainty 
to our diagnosis and prognosis of diseases of childhood as well 
as those of adult life. Obstruction to view of the canal and 
deeper parts is often due to an abnormal lessening of its cali- 
ber or from a superabundant secretion of cerumen, so that it is 
necessary to remove the accumulation with the syringe before 
the examination can be completed. If the auricle, which was 
designed for the collection of the sound vibrations, the meatus 
for sound conduction, the drum-head to receive, the small 
bones of the middle ear to conduct still further, and the inter- 
nal ear and auditory nerve, all possess a normal receptive, con- 
ductive and transmissive power, then the consciousness and 
determinative value of the impressions received and transmitted 
depend upon the functional power of the sound-areas in the 
cortex. 

Hearing in Infancy. — The human offspring differs in its 
higher grade of development from the other mammalia as 
regards the power of audition immediately after birth. The 
perception of sound in the young of all the higher forms of 
life is so dulled during the period immediately following birth 
that it becomes a difficult matter to separate the possible value 
of the hearing sense from that of cutaneous impression. The 
function of perfect hearing in mankind being dependent upon 
a complete developmental expression of the collective, conduc- 
tive, transmissive and perceptive apparatus of the organ of 
hearing, it should not be expected that its perfection is attained 
when the anatomical and histological portion in infancy are 
found so imperfect. 

In a series of experimental observations which I have con- 
ducted at various times upon infants, in the effort to determine 
the power of their auditory function soon after birth, I have 
found it difficult, as it is almost impossible to have the sur- 
roundings in keeping with scientific experiments, so that re- 
peated observations may be necessary to enable one to arrive 
at a conclusion. 

When an examination of the ears, after the removal of the 
fetal accumulation which fills the canal, exhibits the normal ap- 
pearance of the infantile ear, the projection of sounds toward 
the ear, even when loud, discordant or musical, seem to' disturb 
the ten-day-old infant less than vibrations of the same strength 
transmitted through the floor, its crib or cradle. At this age 



HEARING IN INFANCY. 11<) 

the cutaneous sense appears certainly more acute than its audi- 
tory sense. 

While the general theory of sound-sensation is still in doubt, 
there are some theories, such as those which pertain to the re- 
ception and transmission of sound impressions as advanced by 
Helmholtz, which remain as yet undisputed. The mode of 
reception and transmission in the auditory nervous apparatus, 
however, remain for investigation and speculative thought. 

It is still a question whether the optical memory-pictures of 
infantile life have a greater retentive value than those memo- 
ries produced by the sound impressions. Owing to the greater 
development of the eye as compared with the ear at birth, it is 
probable that the visual impressions at this period of life are 
more durable than those of sound. 

The auditory center, which is situated in the temporo-sphe- 
noidal portion of each side of the brain, has the inherent power, 
when properly developed, of analyzing the impression of those 
complex tones transmitted to it, as well as determining the au- 
ditory value of all simple sounds and noises which excite it. It 
also has the power to distinguish for the individual certain 
musical tones, when a proper impression has been made upon 
the organ of corti, and transmitted to the auditory sphere of the 
brain, which results in a conscious appreciation of their rhyth- 
mic blending and the interpretation of their musical significance. 

In the infant, after the first few weeks of world life, as it be- 
gins its perceptive auditory period, the lower and deeper tones 
are probably alone perceived, hence the mother's lullaby is of 
a low, if not always a sweet or musical tone. As the infant ad- 
vances toward childhood, the voice tone of the mother or at- 
tendant becomes higher intuitively as the infant shows appre- 
ciation of sounds of higher pitch, which are now necessary for 
the development of the intricate terminal nervous elements of 
the cochlea. It may be observed, also, that this change of 
tones becomes necessary in order to quiet the child, by lessen- 
ing the effect of the other sonorous disturbing elements, which 
increase as the infant's senses become more acute. 

The organs of sense of the infant, like those of the young of 
many of the mammaUa, are capable of educational development 
in proportion to their individual tuition and the perfection 
reached in the design of the intricate, delicate portions of these 
organs. In all animals sight and hearing are susceptible of 
more rapid development under early and careful educational 
-endeavors than other organs of sense. The circumstances which 
surround the infant, or the direction of the educational effort 
toward one organ or the other, may tend toward the devel- 
opment of the retentive memory of the auditory sphere over 



120 THE DISEASES OF CHILDREN. 

that of the optical center. There seems to be little doubt, 
however, that when developmental conditions are equal, special 
education of the retentive powers of one sphere may enable it 
to surpass the other. It is not improbable that the infant 
learns to recognize the eyes, and perhaps the face of the mother 
and her voice, before either the face or voice of the father, 
the child seeming to retain the memory of the mother, not only 
from more intimate relation, but because the visual and sound 
associations of her are more frequently impressed. 

The lullaby common to all races contains from an ethnolog- 
ical standpoint an interesting rhythmic scale exhibited in the 
folk-lore of all races, and while its purpose is to induce sleep of 
the infant, at the same time it affords the stimulus necessary 
for the development of its auditory power. In the early period 
of infancy the tones of the sleep-song can produce only the slight- 
est and most evanescent impression upon the auditory sphere 
of the child's brain, and yet be sufificient to accomplish their 
purpose. In the study of the probable extent of the hearing 
power of the infant, we find that the value of our observations 
is lessened by possible effect of motion to which the child's head 
is subjected, in the effort to quiet it. The lullabies of any tongue 
seem often ineffectual unless accompanied by rocking, or other 
motions of the mother or attendant, which are transmitted to the 
infant in its early life, when in the arms, lap or upon the back. 
The Indian squaw, with her crying papoose upon her back, 
rarely stops to croon a lullaby, but shortens her steps, and 
with a lifting motion of the body soon provokes a somnolent 
condition of her offspring. The Javanese father, with his infant 
swinging below his chest in a sash hammock, hastens his step 
at the cry of the child and thus quiets it. The disturbance of 
the fluid in the semicircular canals of the ear, and the effect 
upon what might be termed the equilibrium sense of the child 
thus produced, may explain the apparent more potent effect in 
the production of sleep-anesthesia than that derived from the 
most musical lullabies. 

Perhaps there may be an analogous confirmation of the the- 
ory presented in consideration of the fact that whenever prac- 
ticable, the music which produces a quickened step in military 
life carries the soldiers on to victory, perhaps because, in addition 
to their patriotism, their thought of self is diminished by the 
effect produced upon the function of the semicircular canals of 
their auditory apparatus. 

Care of the Ears. — The question is often asked of both 
physician and aurist what should be done in the way of the 
hygiene of the ears and their protection from disease. The 



CAUSES OF EAR DISEASES. 121 

ears of the infant when normal require no attention except that 
necessary for the cleanhness or protection of the auricle; nature 
has provided every requisite for the proper care of the canal. 
The washing of the external ear is as necessary as that of any 
other portion of the child's anatomy : but beyond this external 
appendage it is both unwise and oftentimes dangerous to go. 
In the effort to cleanse what appears unclean, the auditory 
canal may suffer injury from the attempt to remove the nat- 
ural ceruminous protective covering of the walls of the canal. 
Attention should more often be given to the coverings of the 
head and throat, as undue exposure of those parts, more fre- 
quently in climates of rapid changes like ours, result in many 
ear affections ; hence it is well in children to provide for the 
head, ears and throat a light, soft and warm covering during 
the fall, winter and spring months. In the washing of the ears 
it is not necessary nor well to manipulate the auricle too much, 
in the way of pulling, digging or dragging it, as while it may 
not be especially delicate of itself, its relation to the middle 
ear is very close and unnecessary efforts expended upon it 
oftentimes produce deeper changes which affect both the com- 
fort and hearing of the child. 

Washing and wetting the head and hair of the child is often 
deleterious to its ears, particularly so in those children who ex- 
hibit an ear-disease tendency and should only be indulged in 
under the most favorable circumstances and when the care taken 
is such as may prevent the accession of cold. 

Boxing or pulling the ears of the child, while not only cruel, 
is likely to be followed by disturbances of the drum-head and 
middle ear which cause inflammation, affect the hearing and 
may endanger life. 

When the ear is in a normal condition water should not be 
introduced into it by means of a syringe or in any other way, as 
it tends to produce not only discomfort but disease, and by 
moistening the drum-head lessens the hearing at least tempo- 
rarily and often permanently. 

Causes of Ear Diseases in Children. — The peculiar and 
intimate relation existing between the middle ear and the naso- 
pharynx, is a prime factor in the production, during the first 
few years of life, of the great numbers of ear diseases. The 
close connection of the ears and throat, favors the disposition 
to inflammatory affections of the middle ears, which constitute 
the larger percentage of ear diseases occurring in infancy and 
childhood. The mucous membrane lining the nasal portion of 
the pharynx, in which we have the openings of the eustachian 
tubes, presents in childhood a normal, tumid condition, and is 



122 THE DISEASES OF CHILDREN. 

spongy from the rich blood supply sent to it. Between the 
openings of the tubes, the adenoid tissue reaches its highest 
development in the third or pharyngeal tonsil. The tendency 
is always great in every coryza, angina, exanthem, or other 
disease which affects the nose, throat or pharynx, from the swell- 
ing and inflammation of the mucous membrane of these parts, 
toward an involvement of the ears. The breathing of damp 
and impure air may exhibit its deleterious effect upon the nasal 
and pharyngeal mucous membrane, in the production of an in- 
flammation, or a congestion at least, of the mucous membrane 
of the eustachian tubes, which interferes with the function of 
hearing, often before there is any apparent impairment of the 
child's general health. 

The eruption of the teeth or their premature decay are fruit- 
ful causes of ear diseases in early life. As the process of denti- 
tion extends over a number of years, during which there is a 
disposition to sympathetic irritation of the ears, aural affections 
are both common and often persistent. 

Too frequent bathing of the infant, or its exposure to 
changes of temperature soon after birth, imperfect drying of 
the hair of the child after washing, wetting of the feet, or the 
retention of damp clothing, result in the frequent production 
of hyperemia and inflammation of throat and nose, which may 
implicate the ears. 

In this climate there is a great tendency in children of any 
age to catarrhal conditions of the nose and throat, which is in- 
creased by their exposure to the temperature variations often 
present in a single room; the room may be too hot or too cold, 
often the atmosphere is too dry or too moist for the individual 
child, so that the temperatural and the hygrometrical condi- 
tions of the air of its surroundings afford a frequent cause of ear 
complication or the aggravation of an existing catarrhal affec- 
tion. 

The close proximity of the brain to the middle ear in infancy, 
owing to the very intimate connection of the dura mater to the 
mucous membrane of the tympanum, gives rise, from the fre- 
quent variations of the circulation of the child's brain to which 
it is subject, to the production of hyperemias and inflammation 
of the middle ear. 

In infancy the commonest causes of diseases of the ear may 
be stated to be the acute exanthemata, dentition, acute catarrhs 
of the nose and throat, diphtheria and hereditary syphilis. In 
childhood and with older children, in addition to the above, 
typhoid fever and pneumonia furnish frequent ear complica- 
tions, while scarlet fever is the cause of the destruction of more 
ears than all the other causes cited. 



ACUTE CATARRH OF MIDDLE EAR. 123 

Diseases of the External Ear. — Few affections of the 
auricle and external meatus are presented except when eczema 
of the face or tinea capitis of the head causes by extension an 
implication of the auricle, or when either disease leaves a sub- 
acute inflammation of the canal within, or around the region of 
ceruminous glands, so that a discharge is present, often purulent 
in character, which results from the dermatitis. Occasionally 
the canal is the seat of small boils in the ear due to impaired 
nutrition. 

Acute Catarrh of the Middle Ear. — Earache is the 
first subjective symptom of middle-ear congestion and inflam- 
mation. Acute catarrh of the middle ear is its common cause. 
It is rarely present in infancy or childhood from such causes as 
reflex neuralgias. The pain varies in intensity according to the 
extent of the inflammatory process and the amount of pressure 
•exerted upon the walls of the tympanic cavity. This pain, which 
is deep-seated, is increased on pressure below the auricle or by 
pulling it. Together with the pain, there is a sense of fullness, 
deafness, noises in the ears and some febrile disturbances, the 
latter often passing unnoticed. 

Etiology. — Of the general causes mentioned, as producing ear 
diseases, coryza is the most common of those of the acute ca- 
tarrhs of the middle ear, although all other causes mentioned 
may excite it. 

Treatment, — As the earache is the prominent symptom, the 
efforts for its relief are mainly in the direction of some local 
medicament applied to the ear canal. Notwithstanding the fact 
that the practice of dropping something in the ear on the ap- 
pearance of earache is, and always has been a common one, yet 
each year we become more and more impressed with its danger, 
its unreliability for the relief of the pain, and the fact that from 
its indulgence a simple attack of acute hyperemia, or catarrh, 
which should be self-limiting, passes into a more severe and often 
chronic affection of the middle ear. 

Relief is only obtained when the treatment of the congestion 
or inflammation of the nares and naso-pharynx is followed by 
the removal of the accompanying swelling of the eustachian 
tubes and middle ear. Our efforts should be directed to this 
portion of the child's head, rather than to the local medication 
of the outer auditory canal. The use of the air-bag, the nozzle 
of which has been placed in one nostril, while the other is closed 
with the finger, is usually sufficient to open the tubes, clear the 
tympanum of mucus, and often relieves the earache at once. 

The application of dry heat to the auricle, canal, or side of the 
head, by means of a hot cloth, a hop-pillow, or a hot-water 



124 THE DISEASES OF CHILDREN. 

bottle or bag, often gives immediate relief, or lessens the in- 
tensity of the pain, and at the same time affords the safest and 
best of topical applications. 

We have at our command a number of homeopathic reme- 
dies, such as aconite, belladonna, chamomilla, calcarea, dulca- 
mara, hepar sulphur, pulsatilla and mercurius, which exhibit 
remarkably quick results in dissipating the disease when prop- 
erly indicated. 

Acute Suppurative Inflammation of the Middle 
Ear. — Acute otitis media catarrhalis by its terminology is 
limited to such inflammatory conditions of the tympanum in 
which only serum or mucus are secreted as a result of the con- 
gestion or inflammation of its lining membrane. It is, however, 
always the pathological precursor of the suppurative and more 
destructive inflammation of the middle ear, and from which it 
differs only in the intensity of the symptoms and in the forma- 
tion and collection of pus instead of serum or mucus in this 
small cavity. As in all cases where pus forms, a corresponding 
destruction of tissue accompanies it ; and when the discharge 
from the ear is of a purulent character, we should recognize its 
appearance as an indication that a more dangerous condition 
than a catarrhal one has involved the ear, with danger to its 
tissues as well as to the hearing. 

When pus is found in the external auditory canal, it is com- 
monly an indication of a rupture of the drum-head, due either 
to surgical interference (paracentesis), or the result of nature's 
effort to relieve the pressure of the imprisoned pus behind it, 
and to lessen the danger of further destruction or complication. 
Hence, it is usually symptomatic of the presence, or prior ex- 
istence, of a suppurative inflammation of the middle ear, which 
has destroyed the drum-head to a sufficient extent to enable the 
discharge from the tympanic cavity to present itself in the 
canal. It is to be remembered that it is not always pathogno- 
monic of middle-ear disease, as it may be accounted for by an 
inflammation or ulceration of the dermoid and osseus portions 
of the external auditory canal. During infancy or childhood 
the drum-head is much less dense, ruptures more quickly and 
easily, and shows a much greater reparative power, than in 
adult life. 

Etiology. — The same causes which produce the catarrhal va- 
riety, are still active in the suppurative form. Here, however, 
scarlet fever is the most prolific of all causes, measles and diph- 
theria being next in order of frequency. Sea or fresh-water 
bathing is responsible for a large number of cases in older 
children. 



ACUTE S UPP URA TI VE TNFL A MM A TION. \ 2*5 

The symptoms are the same as those of the acute catarrhal 
form, intensified. The pain is more severe, but is generally re- 
lieved by rupture of the drum-head, and the consequent dis- 
charge of pus. This rupture may occur within a few hours 
after the attack has appeared, or more frequently after the 
earache has lasted two or three days. If the drum-head is ex- 
amined before this takes place, the membrane is found con- 
gested, dull, soggy in appearance and bulging outward ; if the 
examination is made after, the canal or meatus is found full of 
pus. If the pus is removed from the canal by gentle wiping 
with absorbent cotton, or gently syringed away, the point of 
rupture is readily seen by the pulsation which is presented at 
the spot. 

In the course of the disease, there is in the beginning an 
acute inflammation of the eustachian tube which causes its com- 
plete obstruction, so that the secretion of pus, following the in- 
flammation which has already passed to the walls of the middle 
ear, not being able to find an outlet by way of the tube to the 
pharynx, is confined in the tympanic cavity. The pressure 
thus exerted upon the walls, tends to extend the inflammation 
upward through the roof and involve the brain, backward to 
the mastoid, or distends the drum-head, and at the same time 
softens it by the inflammatory products thrown into it, until it 
finally gives way with a greater or lesser destruction of its 
tissue. The size of the opening thus made, may vary from the 
most minute rupture, to complete destruction of the whole 
drum-head; as a rule, the extent of the rupture or destruction 
being greatest where the inflammation is accompanied by im- 
poverished blood, as in those malignant cases of scarlet fever, 
diphtheria and measles, when the destructive process usually 
involves all the essential portions of the middle ear. 

Treatment. — While both the acute catarrhal and the suppur- 
ative forms of inflammation of the tympanic cavity tend, like 
many other acute diseases toward recovery, when the discharge 
does not cease or the ruptured membrance heal within the first 
week or two following the attack, the result is to produce a 
chronicity which increases with the age of the child. Hence, 
the earlier the treatment is applied, which carries with it a full 
knowledge of the condition, after a proper and careful examina- 
tion has been made of the ear, the better the result in repara- 
tion of the lost tissue of the membrane of the drum-head, and 
the restoration of the hearing function as well as the preven- 
tion of a chronic condition of the middle ear, which may men- 
ace the life of the child and destroy or lessen its hearing at 
any period of its subsequent life. 

The belief, which has been so common in the past, both 



126 THE DISEASES OF CHILDREN. 

among physicians and the laity, owing to their ignorance of the 
pathological conditions of the ears in these cases, that the child 
would outgrow the discharge from the ear, has caused deafness 
and death in thousands of cases, when proper treatment might, 
at an opportune time, have prevented both. In many cases, 
similar results have occurred from ill-advised, or too vigorous, 
treatment in cleansing the ears with the syringe, or by the ap- 
plication of the various preparations which are intended to con- 
trol the discharge. 

In the majority of cases of both the catarrhal and suppura- 
tive variety of middle-ear diseases occurring in children, it is 
usually only necessary to remove as far as possible the dis- 
charge by wiping the more external portion of the canal with 
a swab of absorbent cotton and the application of a little 
boracic acid to render the secretion less septic. The use of the 
syringe and the accompanying water with its disinfectant or 
antiseptic solution added, while washing away the pus at the 
same time, unless the canal and drum-head are carefully dried 
with the cotton-swab under a good illumination of the canal 
and drum-head, results in the retention of a portion of the fluid 
which, if not already warmed, as all solutions introduced into 
the ear should be, soon becomes of the temperature of the 
surrounding parts, and the elements of a poultice, heat and 
moisture, are presented to the tissues ; this is followed by more 
or less maceration with consequent stasis in the circulation and 
a retardation of the healing process, and at the same time tends 
toward the extension of the ulcerative process and further de- 
struction of tissue. 

During the last ten or twelve years, with a better knowledge 
and a wider experience in the treatment of both the acute and 
chronic suppurations of the middle ear, results of treatment of 
those conditions have been much more brilliant and satisfactory 
than those of the years before. The substitution of the dry 
for the moist treatment, the introduction of boric acid, resorcin, 
peroxide of hydrogen and other topical remedies to our 
armamentarium have largely increased our percentage of cures 
over former years. 

As the acute form tends so often to become chronic, we 
shall find that it is only after the nose and naso-pharnyx have 
received proper treatment, and all anomalous conditions there 
presented are removed, that the ear disease responds promptly 
to treatment, relapses do not occur as before, and a permanent 
cure of the inflammation and its accompanying discharge is 
secured. 

Prognosis. — This is not so favorable as in the non-suppura- 
tive variety, but the early intervention of proper treatment 



CHR ONIC S UPP URA TI VE IN FLA MM A TION. 1 27 

renders the prognosis much more favorable than is generally 
supposed. The majority of uncomplicated cases occurring in 
otherwise healthy children terminate in complete recovery. 
When during scarlet fever, measles or diphtheria this affection 
appears as a complication, the prognosis is usually bad, as the 
destruction of the parts of the ear is often extensive, with 
greater tendency to the formation of adhesions and extension 
of the ulcerative process, owing to the lowered vitality of the 
febrile condition. 

Results. — Recovery with complete or partial restoration of 
the hearing power. Chronic suppuration ; mastoid complica- 
tion ; periostitis, necrosis and caries of the temporal bone ; 
meningitis; cerebral abscess; pyemia and death. 

When in the opinion of the medical attendant it is deemed 
advisable to perform paracentisis of the drum-head, the most 
bulging portion, which is usually found to be the lower poste- 
rior segment, should be selected for puncture. With a good 
illumination of the parts a paracentisis knife is carried through 
the membrane, and upon the withdrawal of the knife a quantity 
of pus follows through the perforation, usually with considera- 
ble relief of both the pain and the inflammation. 

In the internal medication for acute suppurative otitis media 
we find such remedies as aconite, belladonna, calcareacarb., fer- 
rum phos., hepar sulph., mercurius, silicea and sulphur affording 
good results from their exhibition. 

Chronic Suppurative Inflammation of the Middle 
Ear. — This is one of the most common affections of the ear oc- 
curring during childhood, almost all cases in which there is a dis- 
charge from the ear being due to this disease. It is usually the 
sequel of the acute form, but cases present themselves in which 
a tendency to chronicity may be said to be exhibited in the be- 
ginning, as in those cases occurring in tuberculous subjects, or 
when they are the accompaniment of pulmonary phthisis. 

Etiology. — Scarlet fever, measles and diphtheria form the 
most frequent causes, as during the acute period of the ear 
attack, the destruction of tissue has perhaps been great, the 
vitality of the parts so lowered by the impoverished blood 
occasioned by the general disease that the healing tendency 
is very much diminished. Abnormal conditions of the nose 
and upper pharynx when present tend to cause the acute 
variety to pass to the chronic, notwithstanding the aural 
treatment. 

Symptoms and Diagnosis. — The discharge of pus from the 
ear is the common symptom. The quantity varies in amount 
from that just sufficient to moisten some portion of the 



128 THE DISEASES OF CHILDREN. 

walls of the tympanic cavity to constant flow from the ear, 
which fills the canal and flows down the neck or face. There 
are cases in which the pus found in the middle ear passes 
through the eustachian tube and is discharged into the throat 
and finally find its way into the stomach. Deafness is always 
present, varies in degree, from an almost inappreciable loss to 
total deafness. This variation is not dependent upon the size 
or location of the perforation, but upon the changes which 
have affected the tension and mobility of the drum-head. The 
ears are rarely complained of; pain is exceptional, unless there 
is an acute exacerbation of the disease. 

The character of the discharge is dependent upon the condi- 
tion of the tympanic cavity and meatus. The pus in a typical 
case is then laudable, and as the parts heal the secretion be- 
comes more thin and scanty. When mixed with mucus it is 
stringy and hard to remove. When the mucous membrane of 
the middle ear is denuded of its epithelium, very much swollen, 
or granulatious and soft polypi appear upon its surface, the 
discharge is often mixed with blood. The odor of the discharge 
depends somewhat upon the care given the ear ; where the pus 
is allowed to remain and the ears are neglected it becomes very 
fetid. When the odor is bad in cases where proper cleanliness 
is indulged in, it is usually due to a diseased condition of the 
bone, and it is particularly indicative of this when, in addition 
to its fetor, it presents a brownish color. Occasionally the dis- 
charge is made fetid by admixture with an altered secretion from 
the ceruminous glands. 

Perforation of the membrane of the tympanum is the almost 
invariable accompaniment of chronic suppuration of the middle 
ear. The presence or absence of the opening alone enables us 
to determine, when pus is found in the canal, whether the con- 
dition is one of middle-ear disease or a diseased condition of 
the canal. To determine its presence or absence the canal must 
first be cleaned of any discharge, the deeper parts of the ear 
well illuminated, when, if the perforation is of any extent, it is 
readily distinguished by the appearance of the reddish mucous 
membrane lining the inner wall of the drum cavity in the white 
frame afforded by the remaining portions of the drum-mem- 
brane. When the opening is very small it is only detected by 
forcing air through the nostril by some method of inflation 
when, passing through the opening, a whistling sound is heard. 

The size and shape of the perforation varies greatly, from the 
most minute opening to that of complete, or almost complete, 
loss of the entire membrane. It is usually located in the lower 
and posterior portion when of moderate size, and when very 
large commonly involves the lower half. The relation of the 



CHR ONIC S UPP URA TI VE IN FLAM MA TION. 129 

size or location of the perforation to the loss of hearing, as al- 
ready stated, is a difificult one to determine on inspection. In 
proportion as the opening lessens or changes the tension of the 
drum-membrane, or the inflammation which caused it has dis- 
turbed the mobility of the ossicles, is the hearing power dimin- 
ished. If neither the tension nor the free movement of the os- 
sicles is interfered with by the perforation, no serious deafness 
accompanies it. 

The sequelas mentioned under the acute suppurative process 
are to be noted as occurring more frequently under the chronic 
form. Such complications always render the prognosis very 
grave, both as regards life and hearing. 

The prognosis in the majority of cases, with the improve- 
ment in our methods of treatment, is much more favorable 
than formerly. But as the condition is always a serious one and 
as long as it exists is a menace to life, our prognosis must be 
guarded. 

Treatment. — The whole effort in the treatment is to be 
directed toward the restoration of the tissues of the middle ear 
to a healthy condition ; when this is accomplished the discharge 
usually ends. The improvement in the condition of the tissues 
is usually followed by a healing of the perforation when the 
opening has not been too large. The return of the ear to 
health restores the hearing in whole or in part, but continued 
treatment is usually necessary to improve the hearing, when 
deficient, by lessening the adhesions and other changes which 
have occurred in the ear as a result of the prolonged suppura- 
tion. In the treatment it is necessary to have the discharge 
removed with sufficient frequency to prevent the maceration 
of the membrane with which it comes in contact. As already 
suggested, this is better accomplished by the dry method in 
which swabs of absorbent cotton are used to remove it. There 
are some cases, however, in which the syringe is better indi- 
cated, and after its use all the moisture left in the ear should 
be absorbed by cotton introduced for the purpose. The inven- 
tion of peroxide of hydrogen and its effect, when used in the 
ear by thoroughly removing and destroying the purulent 
secretion, has done more than any other remedy in aural thera- 
peutics to increase the percentage of cures in these cases. 
When the discharge has been thoroughly removed, it has been 
customary to apply some astringent solution or powder to the 
inflamed surfaces. There seems to be a consensus of opinion 
of the otologists of to-day that the application made should be 
dry, and of the great variety of powders used in this way, 
boracic acid presents superior claims. In the use of boracic 
acid the amount applied should vary with the quantity of dis- 
D. C— 9 



130 THE DISEASES OF CHILDREN. 

charge. If the discharge is full and free, the external canal 
should be filled with it ; and as the discharge becomes less under 
treatment, it is better not to pack the passage with the powder^ 
as it is then more likely to cake and form a hard plug which is 
removed with difficulty and which, when in situ, may cause 
serious trouble by confining the pus in the middle ear. The 
frequency of its application depends upon the quantity of the 
discharge and it may require daily repetition of the process. 
Its introduction into the ear is readily accomplished by the use 
of the common powder-blower. 

After the process has been finished, a small wad of cotton 
should be placed in the ear to prevent the powder falling out,, 
and also afford protection to the tympanum from atmospheric 
changes. Proof alcohol may sometimes be applied to the tissues 
of the middle ear with good effect. 

Where exuberant granulations or polypi spring up during the 
course of the disease, they should be removed by the application 
of caustics, such as nitrate of silver, resorcin, chromic acid, bi- 
chromate of potash or perchloride of iron, as may seem indi- 
cated from experience for the individual case. The greatest 
care should betaken in their use to prevent destruction of good 
tissue and to limit their action to that portion which we wish 
to destroy. When, as in case of polypi, the mass is too large 
to be rapidly reduced by applications of caustics or astringents, 
the use of a wire snare or the curette becomes necessary. 
After granulations have been destroyed or the polypi removed, 
it is necessary to treat the part from which they were developed 
until it has become covered with epithelium or scar-tissue, 
which prevents their recurrence. 

Mastoid complication is very rare, except that superficial form 
which exhibits itself as an abscess over the mastoid portion of 
the temporal bone. As the mastoid cells do not develop much 
before the age of puberty, we do not have the dread complica- 
tion of true mastoiditis to deal with, as in adult life. The skin 
over the mastoid often becomes tumid, red and the part pain- 
ful, and pus forms beneath the skin or periosteum covering the 
rudimentary cells of the mastoid, and requires only moderate 
poulticing until the abscess may be lanced with relief to the 
imprisoned pus without the more extended operation necessary 
in later life, which requires the opening of the bone cells. 

If the single cell or antrum of the child's undeveloped mas- 
toid becomes inflamed and pus forms, the abscess tends to dis- 
charge itself through the thin cribriform outer plate of the 
rudimentary mastoid, and point in the softer tissues covering the 
part. 

Periostitis, caries and necrosis require attention during the 






CHR ONIC NON-S UPP URA TI VE CA TA RRH. 131 

course of the treatment of chronic suppuration as they appear, 
but hke other sequela already mentioned as complications of 
the disease, they require such care that the discussion of their 
treatment would be out of place in a chapter devoted to the 
consideration of those more common diseases of the ear occur- 
ring in children. 

The general health of the child must in all cases receive due 
consideration ; proper hygiene and improved nutrition are the 
greatest of aids in the effort to cure this disease. We often find 
these patients suffering from dyscrasias, or low conditions per- 
haps due to malnutrition, and before attempting to cure the 
ear disease we shall save time if we will devote attention to 
those measures which would result in the improvement of the 
general health. A proper, and often a specially nutritious, diet, 
fresh air, and the improvement resulting from them will again 
and again indicate to us, that the ear is only a part of the whole, 
and that the condition of the part depends in its local affection 
upon the condition of the whole. 

When we have removed the exciting causes as far as found, 
or improved the ear condition as far as possible by such local 
measures as may be expedient, we should look closely into the 
symptoms, both local and general, which may give us the indica- 
tion for the prescription of the homeopathic remedy which will 
result in the curing of cases which otherwise would go on to 
further destruction. 

Among the remedies which may be indicated, there are few 
in addition to those already mentioned under the head of the 
acute variety ; but it will be well in cases of doubt to read care- 
fully the general aural indications of the more common reme- 
dies, which may be indicated in ear diseases, and which are 
found on page 141. 

Chronic Non-suppurative Catarrh of the Mn)DLE 
Ear. — This disease has for its most significant symptom an 
impairment of the hearing. The deafness, while not always 
readily recognized, is more or less marked, or may even be com- 
plete, long before there is more than a suspicion of the defect 
arising in the minds of the child's attendants. Its beginning 
in children, as well as in adults, is so insidious that it is only 
brought into recognition and relief sought, when the deafness 
arising from it is so great as to become sufficiently noticeable, 
and to call into question the want of proper intellectual devel- 
opment for the child's age. The child may show slow or no 
response to calls or queries addressed to it in the ordinary tones 
of conversation ; when its age is such that otherwise, from a 
normal hearing apparatus and well-developed function, it should 



132 THE DISEASES OF CHILDREN. 

be able to respond properly to the interrogative sound impres- 
sions which are directed to, and impressed upon it. 

Symptoms. — The deafness, which varies from day to day, and 
is worse frequently when the weather is damp or cold, or from 
coryzas which assail the child, presents the most common 
symptom. 

Subjective noises in the ear are, in the child suffering from 
this affection, rarely spoken of, except in older children, and 
even then only when questioned as to their presence. The 
sounds as noticed by children are usually of a singing or ring- 
ing character, and are often absent entirely ; or a crackling 
sound on swallowing is described. The more frequent cause 
of complaint is that the voice sounds are like those which are 
produced by many talking in a room ; in fact, sounds are con- 
fused, and there is no clear conduction or proper reception. 

The examination of the canal and of the external meatus 
reveals, perhaps, a want of cerumen or a hyper-secretion of it. 
The latter is the more common condition in youth, while its 
absence is the usual accompaniment of the same condition of 
the middle ear in the adult. 

The drum-head exhibits changes in position and appearance, 
and when retracted it presents a dimness of color, or loss of 
brilliancy reveals to us the changes which have occurred in the 
middle ear, and which account for the loss of hearing in the 
individual case. 

In children old enough to talk, the vowel sounds are often 
mistaken for the consonants, or mistakes are made in the repe- 
tition of words during the testing of the hearing, as " pin " for 
*' man," or " man " for *' pin ; " or " four " for '* more." And it 
will often be found that the hearing is so deficient, that words 
are only properly repeated by the child when pronounced in a 
loud tone within a few feet or inches of its ears. 

Earaches occur as the result of an acute exacerbation of the 
chronic catarrh, and indicate only a passing increase of conges- 
tion of, or a severe inflammation of the middle ear. 

The external ear, and the tissues in immediate connection 
with the external auditory canal are often sensitive to atmos- 
pheric cold, to touch or pressure, or the necessary manipulation 
undergone during the washing of the ears. 

Sneezing is not uncommonly an accompanying symptom of 
catarrhs of the middle ear. 

Etiology. — The causes which lead so often to affections which 
produce in infancy, childhood, or adult life direct loss of hear- 
ing, have been considered under those diseases of the ear al- 
ready discussed in this chapter under the topical headings of 
the acute and chronic suppurative or purulent inflammations 



CHR ONIC NON-S UPP UP A TI VE CA TA RRH. 1 33 

of the middle ear. In the chronic affection of the middle ear, 
when the disease presents a hypertrophy, hypersecretion of 
mucus, or a thickening of the membrane lining the cavity or 
enveloping the ossicles, then diseases to which the parts have 
already been subjected by the inflammatory processes enumer- 
ated, present a direct and indirect causative relation. The se- 
quela of all those diseases of the infant or child which it has 
passed through may leave as their aftermath an impression 
upon the essential portions of the auditory organ which finally 
result in a deafness too often progressive and complete. The 
exanthemata thus produce directly or indirectly more cases of 
deafness during the early period of childhood than all other 
diseases, and present the same proportionate causes of deafness 
in the adult. 

When the factors just mentioned are eliminated from statis- 
tics which show the etiological percentage of deafness, we find 
both in childhood and in adult life, particularly the latter, 
that the loss of hearing is due to those catarrhal affections of 
the nose and naso-pharynx which are so common in our cli- 
mate. One may become as fatigued discussing the question of 
possible cure of general catarrhs as he does of the consideration 
of the necessity of having so many bespectacled children about 
us. The onset of a catarrh, which invades the nose and throat 
and involves the ear, and which should require early attention, 
is so often unnoticed in the beginning that it is only when the 
direct affection of the middle ear exhibits a marked impairment 
of the hearing, or when a succession of colds affecting the head 
which are accompanied by a temporary lessening of the hearing- 
power, finally present as an accumulative effect a hearing- 
loss which is sufficient to be noticed by the child's attendants. 

When the child suffers from recurrent attacks of cold con- 
fined in its expression to the head or nose, and as a result 
breathes through its mouth, or when old enough its articula- 
tion has a nasal intonation, or its hearing power is questioned, 
the examination of the nose, throat and ears may reveal the 
cause of the discomfort of the child and the condition of the 
ears which causes its deafness. 

There can be little doubt that heredity as well as climate is 
a predisposing cause of catarrhal middle-ear affections of a 
chronic nature, with progressive changes which are followed by 
deafness. 

The hygienic conditions of our houses, the defects in ven- 
tilation and sanitation, both in our houses and the schools in 
which we live or place our children, are so often at fault that 
we have little need to wonder at the increasing number of cases 
of middle-ear catarrh which daily seek treatment. 



134 THE DISEASES OF CHILDREN. 

Prognosis. — The course of the disease is usually slow ; the 
variations which occur in the mucous membrane, whether one 
of proliferation or of atrophy, finally result in changes that 
cause a retraction of the drum-head, the stiffening of the chain 
of ossicles, and general impairment of at least the receptive 
and conductive portion of the ear, which is followed by a pro- 
gressive loss of hearing. 

The prognosis in childhood is far more favorable than in 
adult life. The early treatment of the nose and throat and 
the direct care of the ears cure and remove the chronic ten- 
dency in the majority of cases thus treated. 

Treatment. — The treatment of this disease depends upon 
the exciting causes which have given rise to it and the char- 
acter of the affection of the tissue of the middle ear. In in- 
fancy and childhood the catarrhs of the nose and throat 
partake of the hypertrophic form, wherein there is a moist 
rather than the dry catarrh which is found more frequently 
later in life. 

An examination having determined the form of catarrh 
which involves the nose and throat, we proceed to relieve that 
by proper treatment, as in so doing we remove the cause of the 
origin of the middle-ear affection or its aggravation. In the 
treatment of these parts sprays are of great value, the me- 
dicinal components of them depending upon the particular 
condition of the membranes presented. They may be anti- 
septic, cleansing or therapeutic, as the judgment of the phy- 
sician may deem advisable. Snuffing fluids up the nose or the 
use of the nasal douche should be discontinued by every medical 
adviser. The danger of exciting acute middle-ear inflam- 
mations is great, as when the fluid passes to the post-nasal 
portion of the pharynx the involuntary action of swallowing 
being followed by an opening of the eustachian tubes, the 
fluid is carried into the tube or into the middle ear and an 
acute inflammation of the tympanic cavity is the result. 

Popular catarrh remedies, which from their advertisements 
should enable us to find in them a cure for all cases of 
catarrhal deafness, seem, when used, to increase the number of 
aural affections, by the irritation of the nose and naso-pharynx 
from insufflation of the powders or snuffing up the fluids of 
which they are composed. 

As the air-passages of the head were designed for the purpose 
of preparing the air we breathe for its proper change in the 
lung-tissue, due consideration should be given to the condition 
of the nose and throat, and at the same time the after-effects 
which a too vigorous treatment of the parts may have upon 
the welfare of the child in regard to its lungs or aural organ. 



CHRONIC NONSUPPURATIVE CATARRH. 1:J5 

In the effort to remove the exciting or aggravating causes 
of this disease, there is much to consider in both the improve- 
ment of the hygienic conditions of the child as well as the 
treatment which is to be directed to the aural condition. 

Whenever there is a chronic ear tendency, as evinced by 
occasional deafness or recurrent attacks of ear-ache, or dis- 
charge from the ear, the clothing of the child is to be inquired 
into, as well as its nutrition. Wet feet and damp clothing 
promote diseases of the aural as well as all other organs of the 
body. In our climate, which from the writer's observation, is 
no worse than others, there is a necessity for skin-protec- 
tion which seems from experience only to be gained by the 
use of wool underclothing in these cases during all seasons. 
The adult or the child with a vigorous constitution may 
replace its flannels with cotton as the season advances toward 
summer, but we find that the changes from heat to cold to 
which we may be subjected in this climate provokes, when 
the skin is not protected by a garment containing in its com- 
position a fair proportion of wool, both aural and general 
catarrhs. 

W^hile all cHmates may have their defects and at the same 
time, aggravate, lessen, or cure general and aural catarrhs, when 
the question is asked, Where we shall take our child that it may 
be relieved of the effect of the sudden changes incident to its 
place of habitation, or avoid, or lessen the possible climatic 
effect upon its catarrhal condition, both general and aural, the 
climatologist gives only a general rule, which does not enable 
us to answer the question properly. It does not matter always 
how good a student one may be of climato-therapy, if he fails 
to designate as the particular climate in this country or others, 
or the precise location which, from its altitude, geographical 
position and average temperature reports, would seem to be 
best for the individual. No specific direction can be given, even 
when a knowledge of the local catarrhal condition is beyond 
doubt, when our efforts to relieve or cure the condition by 
change to other climates, are followed by results, which should 
not follow from statistical reports furnished. We may advise 
that the patient seek in Tennessee, North Carolina, Georgia, 
Florida, or any of our southern states of the east, or California 
in the west, or in those intermediate climates of Arizona, New 
Mexico, or Colorado, which may furnish that particular climate, 
with its proper altitude, lessened humidity of atmosphere and 
less marked changes of temperature, which we hoped will 
be beneficial to him and prove remedial to the individual's ca- 
tarrhal condition. The altitude and the greater dryness of the 
atmosphere, due to geographical location, the improvement of 



136 THE DISEASES OF CHILDREN. 

the hygienic surroundings, which latter may after all be the 
most beneficial in retarding, limiting, or curing this progressive 
disease of the middle ear, make us often question the value of 
the climato-therapy. 

Adenoid growths, and the pharyngeal tonsil, when much en- 
larged, may require removal. It should be remembered, how- 
ever, that these adenoid bodies and the enlarged tonsil tend 
toward disappearance before puberty, so that, except when they 
are a recognized aggravation of the aural trouble, from direct 
pressure upon the eustachian tubes, it is better to avoid surgical 
interference, as the attempt to remove them is often followed 
by an acute inflammation of the middle ear, with the result of 
destroying the hearing or aggravating the aural trouble. 

The turbinate bodies often present a turgescence, which in- 
terferes with the respiration. They are not always the cause 
of the mouth-breathing which may be present, and while their 
swollen condition, due to their tumidity, may impede the child's 
breathing, it is not always necessary to remove them in whole 
or in part by thermo or electro-cautery, or caustic measures, or in 
any other manner, as their enlargement is often only temporary 
and we should consider the need which, both as child and adult, 
it may have in the future for the membrane which may be thus 
destroyed. Time will probably develop the fact that the de- 
struction of these membranes and other contiguous portions 
have much to do with the individual's future systemic economy. 
When we consider that a pint and a half of serum is secreted 
every twenty-four hours by the mucous membrane lining the 
nose and throat, for the purpose of filtering, moistening and 
warming the air we breathe, it is a question whether these 
tissues, which nature has provided for the proper protection 
and sanitation of the lungs, should not be retained as they 
may be in many cases, or removed or destroyed in the imme- 
diate effort which may seem necessary for the temporary 
relief which perhaps accompanies such measures. Already 
from my observation, cases present conditions as a result of 
surgical interference in this direction which, while it has bene- 
fited the child at the time, has deprived it of a protection 
against disease, when better results might have been attained 
by a purely medical treatment. 

Where the hearing becomes so impaired from any cause that 
the child no longer hears the tones of the human voice, if it 
is under five years of age its power of speech is also lost, hence, 
in the effort to prevent deaf-mutism, it becomes necessary to 
apply the treatment as early as possible. In these cases, while 
they are undergoing the treatment for the aural catarrh, they 
should be compelled to keep on talking and not be allowed to 



INTERNAL EAR. 1:J7 

resort to the sign language. If the ear trouble can be even 
partly cured, there is a very fair chance of their retaining their 
speech under these circumstances. 

In the treatment of chronic aural catarrh, it is imperative 
that the eustachian tubes and the tympanic cavity should be 
thoroughly inflated with air after the method of Politzer. The 
ordinary air-bag is moderately compressed by the hand, after 
the nose-piece of the bag has been placed in one side of the 
nose and the other side closed by the finger. As a rule the 
inflation is accomplished in the majority of cases with little 
difficulty ; the operation clears the cavity of the middle ear of 
serum or mucus, replaces the drum-head in position, and is 
often followed by a marked improvement in hearing, which, 
however, is as often lost before the succeeding treatment brings 
with it another inflation. As the condition of the ear im- 
proves, the effect of the inflation is more lasting, and finally in 
cases which are cured becomes permanent. 

The action of the homeopathic remedy in this disease is 
prompt and at times marvelous in cases when the true remedy 
is prescribed. The remedies which are more frequently indi- 
cated are: arsenicum ; argentum nit. ; aurum mur. ; belladonna, 
calcareacarb. ; calcarea phos. ; causticum ; ferrum phos. ; graph- 
itis ; hepar sulph. ; kali mur. ; kali phos. ; mercurius dulc. ; phos- 
phorus, etc. 

The special indications will be found in the general list of 
aural remedies given on page 97. 

Internal Ear. — The internal ear, or labyrinth, in which is 
lodged the delicate mechanism that terminates the nerve of 
hearing, is situated just beyond the middle ear, and in adult 
life well protected by the solidification which comes with the 
full development of the temporal bone. It is readily affected 
by diseases and injuries of the middle ear, and also of the brain, 
with both of which it is intimately connected during child life. 
The temporal bone, not having reached that growth and com- 
pactness which comes in later years, does not afford that pro- 
tection from both disease and injury which is reached later; 
hence the internal ear is more susceptible to diseases which 
destroy its function in early life than in the adult. 

The concussion of the head from blows or falls, readily com- 
municates its effect to the labyrinth and the hearing is thus 
often destroyed. Such diseases as cerebro-spinal meningitis, 
mumps, hemorrhagic inflammation of the internal ear, and in- 
flammatory extensions from the middle ear to the labyrinth in 
scarlet and typhoid fevers, and acute or chronic suppurations 
of the middle ear, furnish a large number of internal ear dis- 



138 THE DISEASES OF CHILDREN. 

eases which, from their invasion of the labyrinth, destroy the 
hearing and produce in the younger children deaf-mutism. 

The destruction of the essential portions of the internal ear 
are not rare to the aurist, although much less so to the general 
practitioner. Of the causes which occasion it, twenty-five per 
cent, are those of meningitis and cerebro-spinal meningitis, 
while scarlet fever presents the next most frequent cause. 
These diseases produce internal ear inflammations by direct 
extension from the brain or middle ear. But such diseases as 
small-pox and parotiditis in children, also produce internal ear 
complications which cause destruction of the auditory nerve or 
of its function. Imperfect development of the internal ear due 
to pre-natal causes, frequently exhibit, on post-mortem exami- 
nation, sufficient cause of the infant's deafness. 

The symptoms which may indicate an affection of the in- 
ternal ear in infancy or early childhood, are so often similar to 
those arising from affections of the contiguous parts, that it is 
difficult to differentiate between the symptoms which arise 
from an acute inflammation of the middle ear and that of 
the internal ear, as one may exist alone or complicate the 
other, and during their inflammatory stage simulate those 
symptoms which are presented in affections of the meninges 
or the brain. 

In children too young to express the location of their suf- 
fering by words, we may thus be often in doubt as to the 
organ which is diseased. The cry of the infant, which is 
always a symptom of discomfort, if not of disease, should 
require attention, that its comfort may be assured and the 
possible disease be averted. When the symptoms of affections 
of more remote organs have, as the possible cause of the 
child's pain, been eliminated, the diagnosis of the probable ear 
or brain affection becomes a necessary consideration. 

One often finds as much difficulty in distinguishing the ''cri 
cephalique " of meningitis from the '' cri " occasioned by acute 
middle and internal ear disease, as he does in determining the 
value of those symptoms which indicate a capillary bronchitis 
or pneumonia in infancy when their possible cause is due to a 
reflex of middle or internal-ear inflammation, until an exami- 
nation of the ear is made, or when a punctured or ruptured 
drum-head gives relief to the sufferings of the child and causes 
a change of opinion as to the diagnosis and prognosis. In the 
infant, as we are dependent upon the objective symptoms 
for our diagnosis and prognosis, the close study of the symp- 
toms presented enhance both their diagnostic and prognostic 
value. When in the absence of marked increase of temperature 
and no special variation in the digestion or the action of the 



INTERNAL EAR. 139 

bowels the infant rolls its head from side to side and in its rest- 
lessness cries out in that tone which has been designated the 
*' head-cry," or when the movement of the head by the attend- 
ant gives evident pain to the child, it is probable that an im- 
plication of the ear may be the cause of its suffering rather 
than an affection of its brain or other portions of its anatomy. 
The loud and passionate cry of the infant, together with the 
aggravation from movements of the head and the temporary 
relief afforded by resting the head upon one side or the other, 
may give a clue to the real affection. For example, a child 
is attacked with a sudden fit of vomiting, which recurs at in- 
tervals during the several succeeding days and presents a 
temperature somewhat above the normal with more or less 
marked chill. Within the first twenty-four hours of the at- 
tack no difficulty in hearing is noticed, but the following 
day brings with it a deafness which is complete. The child's 
brain remains clear, and no convulsions, paralysis or opistho- 
tonos are present. In a week the child recovers its appetite 
and indulges in play, but it is noticed that there is complete 
deafness and that there is also an unsteadiness of its gait, 
and it requires often to be led to prevent frequent falls. 
We examine the auditory meatus and the drum-head, and 
find no variations from their normal condition sufficient to 
account for the symptoms presented. The close study of 
the symptoms, however, are followed by a diagnosis of inflam- 
mation of the labyrinth. We must differentiate between 
this affection of the internal ear, which might be termed 
idiopathic and that which results from hemorrhagic inflam- 
mation, which is not uncommon during the infantile period, 
and those arising from such inflammatory extensions as fol- 
low cerebro-spinal meningitis, injuries and complications aris- 
ing from diseases of the middle ear alone, or accompanied 
by those diseases which affect the general economy of the 
child as well, largely by the history as well as the symptoms 
presented by the disease. Such drugs as quinia, salicylic acid, 
salicylate of soda, salol and some of the coal-tar products which 
have come into such prominent favor, have, when administered 
in individual cases, produced permanent middle and internal- 
ear changes, which have been followed by loss of hearing and 
deaf-dumbness as well. 

The destruction of the auditory nerve or its function from 
any cause in children under the age of seven years means to 
the child, if it lives, not only the loss of audition but also 
that of whatever power of expression of speech it may have 
acquired prior to its deafness. Unless early attention is 
called to it and educational treatment followed, the possible 



140 THE DISEASES OF CHILDREN. 

retention of the vocal expression it may have had, or the ac- 
quirement of the power of speech in the absence of audition, 
is frequently lost. 

While treatment of the ear, both local and internal, may be 
followed with some gain in the hearing in these cases, the re- 
sults are usually only those which, by the slight improvement 
gained, aid the child in its proper education as a deaf mute. 

It is necessary, then, when medical or surgical relief cannot 
restore the child's hearing, to advise such measures as may 
enable the child, by proper education, in its forlorn condition, 
to acquire by intelligent training, the power of speech in the 
absence of its hearing. 

We have now in all large cities, homes and schools which are 
designed to meet the necessity for the physical, moral and 
intellectual training of those children who are both deaf and 
dumb. The good results obtained from this educational treat- 
ment of the diseased conditions, which cause complete deafness 
in childhood, seem wonderful to even those who have given the 
matter thought. The instructions afforded in these institutions, 
which enable the child to gain or acquire the power of speech, 
from the expression and motion of the lips or the mechanical 
vibration of the larynx of the teacher when felt by the child, is 
such as to give to those deaf mutes, which have good intelli- 
gence and normal vocal organs, the power of conversing in any 
language which has thus been taught, and often present a 
general knowledge and education which seems incomprehen- 
sible to those who hear. 

Much may be accomplished by treatment, in the way of the 
absorption of inflammatory deposits in the internal ear, or the 
dissipation of the effects of the disease which has destroyed its 
functions by such homeopathic remedies as hepar sulph., silicea, 
calc. carb., ferrum phos., and the employment of like remedies, 
strychnia, gelsemium, and the salicylates, which may have 
a revivifying and stimulating effect upon the auditory nerve. 
Such adjuncts as electricity, and other local measures which 
may improve the condition of the middle ear or its throat por- 
tion, are to be considered. 

When a child has lost its articulation as a result of disease of 
the internal or middle ear, we should direct the attention of the 
parents or guardian of the child to the necessity for that educa- 
tional treatment of the child, which may enable it to acquire a 
knowledge and education not otherwise attainable, and which 
may give it the ability to hold a position in the community 
in which it resides, oftentimes higher than that of some others 
with normal hearing and less intellectual development. 

The education of the deaf and dumb child should be beguni 



AURAL REMEDIES. 141 

as soon as possible after its deafness has been determined. 
Every effort should be made to have it learn to articulate and 
discourage its effort to communicate by signs. 

When a child appears stupid, inattentive, or does not keep 
pace with its associates in the intellectual race at kindergarten 
or school, humanity demands an investigation of the ears, as 
well as the eyes of the child, by a competent medical adviser, 
who may find that the fault is not in lack of cerebral develop- 
ment, but loss of audition. The hearing power of the teacher 
is frequently less than it should be, and what appears to be only 
the fault of the child, may be due to impaired hearing upon the 
part of both the tutor and child, or want of judgment upon 
the part of the teacher when the child's hearing is impaired. 
The child at school with imperfect sight or hearing, too often 
seems to have assigned to it the desk most remote from the 
blackboard, or the teacher's platform. The teachers of to-day, 
however, recognize the fact, that they themselves may also 
have faulty eyes and ears ; and when cognizant of such defects, 
are more charitable to the children under their educational su- 
pervision. When complete deafness is present, its recognition 
is usually easy for the teacher ; but when only partial, the child 
suffers from non-appreciation of its defective hearing, is placed 
at the foot of the class, and reprimanded for inattention, or said 
to be stupid. To one who is brought by his professional rela- 
tion in close contact with these children, who are too often the 
innocent sufferers of both mental and physical punishment, be- 
cause of their defective hearing, it seems an earlier considera- 
tion of the possible defect should be given in all cases, where 
other causes which may occasion them are absent, and an 
examination by an aural expert be advised. 

Aural Remedies. — The homeopathic indications of the 
most common aural remedies are grouped together here, and 
have been taken from Prof. H. C. Houghton's work on Clinical 
Otology, as they present the most valuable summary extant. 

Aconitiim. — In acute suppuration of the middle ear, or for 
acute symptoms arising in chronic cases. 

Aiiriim Met. — Is indicated in suppurative inflammation of 
the middle ear when the periosteum of the temporal bone is 
affected. The subjective symptoms, so far as the ear is con- 
cerned, are decidedly negative ; but the general ones make the 
choice between this remedy and fluoric acid, nitric acid, or 
silicea, easy. 

Baryta Muriatica. — Baryta is one of our most valuable rem- 
edies, both in suppurative and non-suppurative inflammation 
of the middle ear. Hardness of hearing, severe buzzing in the 



142 THE DISEASES OF CHILDREN. 

ears, crackling in both ears when swallowing, a reverberation in 
the ear on blowing the nose. 

Belladonna. — In acute inflammation of the middle ear, or 
when acute symptoms arise in chronic disease. 

Calcarea Carbonica applies to the same class of patients as 
in general diseases — the fat, rapidly growing, large-headed, 
soft-boned children, or adults who in youth were vigorous, but 
now fail from low power of assimilation ; great weakness, sensi- 
tive to cold, damp air. The pains about the head are pressing 
or pulsating, often semi-lateral ; coldness or perspiration of the 
head ; detonation in the ears ; meatus filled with whitish^ 
fetid pus or viscid discharge. 

Capsicum. — For chronic suppuration. The pains in and 
around the ear are acute, shooting, pressing, with bursting 
headache. On the mastoid, behind the ear, a swelling painful 
to touch. 

Elaps Corallinus. — Indicated in the chronic suppurative form 
of disease, complicated with naso-pharyngeal catarrh ; the pos- 
terior wall of the pharynx covered with crusts ; external meatus 
full of offensive yellowish-green discharge, which stains the 
linen green ; membrana tympani usually perforated. 

Ferrum Phos. — Schussler claims that this salt controls the 
beginning of disease. '* Whilst iron restores to their normal 
condition the blood-vessels, enlarged by disease, it heals the 
irritative hyperemia, which is the cause of the first stage of all 
inflammations." This remedy has been called '' tissue aconite.'* 
One characteristic may guide to its use — beating in the ear 
and head ; the pulse can be counted in the ear, one patient 
remarked. 

Gelsemium. — While this remedy may be more frequently 
needed in acute disease of the middle ear, it may be specially 
effective in mastoid disease, or acute necrosis, complicating 
acute suppuration. 

GrapJiites. — The relation of this remedy to the nutrition of 
the skin holds good in dry conditions of the mucous mem- 
brane; indeed, we may infer very much of the condition of the 
tympanum from study of the dermoid layer of the external 
auditory canal. Hence, the condition is that of sclerosis or 
proliferous inflammation. The membrana tympani may be 
opaque and thick, or transparent and very thin, adherent to 
ossicula or promontory, or perhaps mobile ; eustachian tube 
dilatable, but hearing not improved by inflation. There is one 
subjective symptom which is characteristic — '' hearing improved 
in a noise." 

Hepar Sulphuris Calcarea. — In the suppurative form ; mem- 
brana tympani perforated ; ulceration angry ; discharge small 



AURAL REMEDIES. 14^ 

in amount, sour, and of fetid odor; the tissue very sensitive, 
often covered with white shreds, which cHng to the ulcer. 
Subjective symptoms: soreness in small spots about the ear; 
itching ; patient worse at night and by cold air. 

Hydrastis Canadensis stands first among remedies for muco- 
purulent discharge from the middle ear. In purulent inflam- 
mation of the middle ear, with thick, tenacious discharge, more 
mucus than pus, this remedy is invaluable. 

Iodine. — In chronic, non-suppurative disease. Curative in 
atrophy of mucous membrane, probably by stimulating glandu- 
lar elements of structure. 

Kali Bichroinicum. — In chronic suppuration ; membrana tym- 
pani perforated ; the cicatrization of the edges of the perfora- 
tion complete ; the tissues have an appearance as if changed 
to mucous membrane, and the secretion is often more mucus 
than pus ; the discharge yellow, thick, tenacious, so that it 
may be drawn through the perforation in strings. The sub- 
jective symptoms are lancinations, sticking sensations, that 
the patients are not able to locate with any degree of posi- 
tiveness. 

Kali Muriaticum. — One of the most effective remedies we 
have ever used for chronic catarrhal inflammation of the middle 
ear, specially of the form designated *' proliferous." Subjec- 
tive symptoms, a stuffy sensation in the recent cases, subjective 
sounds, and deafness are very marked. The objective symp- 
toms are, the naso-pharyngeal tonsil, closed eustachian tube, 
retracted membrana tympani and atrophied walls of the ex- 
ternal meatus. 

Kali Phosphoricum. — For suppurative disease, specially 
chronic form, Schussler says: "Potassium phosphate cures the 
following diseased conditions : septic, scorbutic bleedings, mor- 
tifications, encephaloid cancer, gangrenous croup, phagedenic 
chancre, putrid-smelling diarrhea, adynamic typhoid condition, 
etc." From the foregoing indications, we are led to use it in 
ulceration of the membrana tympani, with or without perfora- 
tion, in suppuration of the middle ear, the pus being watery, 
dirty, brownish, very fetid, the ulceration angry, bleeding 
easily, and showing little tendency to granulate, or secret laud- 
able pus. 

Kali Siilph. — For catarrhal disease or suppuration, if the 
discharge be muco-purulent rather than purulent. The guid- 
ing symptom is the color of the secretion, which is yellow, sticky 
and tenacious. 

Mercurius Dulcis. — In chronic catarrhal inflammation of the 
middle ear. The objective symptoms are those of this form of 
inflammation, — membrana tympani retracted, thickened and 



144 THE DISEASES OF CHILDREN. 

immovable by inflation ; a granular or hypertrophied condition 
of the pharyngeal mucous membrane. The subjective ones are 
those of a benumbed, dull feeling between the throat and ear, 
a pressure in the ear from without. 

Merciirius Solubilis. — Otitis following exanthemata, and in 
scrofulous and syphilitic patients, pain in ear, extending to 
face and teeth, worse by the heat of bed ; excoriation and ul- 
ceration of meatus ; sensitive to cold ; abundant secretion of 
cerumen or flow of pus and blood ; sweating without relief, oc- 
curring from cold, when there are hypertrophied tonsils or 
diseased parotids ; pulsative roaring in the affected part ; ulcera- 
tion of the membrana tympani, which bleeds from the slightest 
touch; constant cold sensation in the ears. 

Phosphorus corresponds to a dry condition of the tympanum. 
One objective symptom, deafness, is interesting in this re- 
spect, that the failure is especially for the human voice ; noises 
and musical tones are recognized much more readily than the 
modulations of voice. 

Psormum. — A remedy closely allied to sulphur. In chronic 
suppuration, where the symptoms remain unchanged after sul- 
phur, the ulcers scab over rapidly ; the pus very fetid, with the 
ulceration of the membrana tympani ; scabby ulcers on the ver- 
tex and behind the ears. Subjective symptoms : excessive 
itching in the ears, so that children can hardly be kept from 
picking or boring in the meatus. 

Pulsatilla. — For acute catarrhal inflammation, or chronic 
suppuration, when the discharge is a bland muco-purulent secre- 
tion. Fever without thirst, relief of pains in the open air, and 
a peevish, changeable, timid disposition, indicating the nervous 
depression, are guiding symptoms. 

Silicia. — In chronic suppuration ; ulceration in cachectic sub- 
jects, or those who have been dosed with mercury ; in caries or 
necrosis. Objective symptoms : membrana tympani perfor- 
ated and irregular ; secretion of pus scanty ; ulcers deep, and 
covered with scabs unless frequently cleansed. More repairs 
of the membrane occur under the use of this remedy, in chronic 
diseases, than under any other single remedy. 

Sulphur. — The indications for this remedy must be sought in 
general rather than in special objective ones, as they are meager 
compared with the last-mentioned remedy as well as others. 
Itching in the ears, drawing or shooting pains in the ears ; dis- 
charge of pus, stinking, with crusts. 

Tellurium. — Curative in chronic suppuration, when the 
symptoms correspond to the following : a watery fluid, smell- 
ing like fish-pickle, which excoriates the meatus and the skin 
wherever it flows. After the suppuration has ceased, the 



RELATIVE DISEASES OF THE EAR. 145 

membrane has been found cicatrized and corrugated, but not 
thickened. 

Thuya Oc. — The special indication for this remedy is the dis- 
charge " smelling like putrid meat." Clinically it has cured 
granulations in the meatus similar to condylomata. 

Diseases of the Ear in Their Relation to the Gen- 
eral Economy of the Child. — Affections of the ear as well 
as those of the eye have a causative value in the production 
of diseases of other portions of the child's anatomy. While 
the possible complications which may arise and affect other 
parts of the child's system have been already mentioned in 
the discussion of the direct inflammatory affections of the ear, 
it may be well to recapitulate here the general systemic affec- 
tions, which may accompany or follow diseases of the ear. 

When the infant in its distress, presents objective symptoms 
of suffering sufficient, in the judgment of its attendant, to call 
a physician for relief, it may be difficult for him to formulate 
an opinion at once as to the exact lesion which may be present. 
It should be considered before a diagnosis or prognosis is made, 
that while the symptoms may be those of meningitis, cerebro- 
spinal meningitis, capillary bronchitis, pneumonia, cerebral irri- 
tation with convulsions, that an affection of the ear may be 
the cause of the symptoms which may lead to an erroneous 
diagnosis. 

Foreign bodies in the ear may occasion, by irritation of the 
walls of the canal, a reflex through the third branch of the fifth 
and pneumogastric nerves, which may result in development 
of what appears to be true epileptoid convulsions, or, perhaps, 
even a paralysis, or paresis of parts of the same side of the 
body as that of the ear which contains the foreign substance. 
It should also be mentioned that similar foreign bodies may re- 
main in the auditory canal for an indefinite period, without ex- 
citing any such reflex disturbances in another child, owing to a 
less abnormal development of the nerves supplying the audi- 
tory meatus, or the absence of a hyper-sensitive condition of 
the child's nervous system. 

There is a form of epilepsy which has its origin in otitis me- 
dia, usually of the chronic suppurative type, where the attacks 
are excited by inflammatory thickening, or from irritation of 
the middle or internal ear, resulting from pressure due to in- 
flammation or from nerve irritation arising during the destruc- 
tion of the parts. It is more frequently found associated with 
caries and necrosis of the internal ear, and of the temporal bone. 
The mastoid, when diseased, also holds a causative relation oc- 
casionally. In all cases of epilepsy, where there is a history of 
D. C— 10 



146 THE DISEASES OF CHILDREN. 

aural disease, or where aural symptoms are present, it is well ta 
examine into the condition of the ear. 

Where there is a more or less constant discharge from one or 
both ears of the child, which from neglect, or want of proper 
treatment, or even when the best available treatment has not 
caused its cessation, the child then exists with a condition which 
menaces its life at all times, and which may at any time on the 
accession of an increased inflammation due to cold, or the ex- 
tension of the ulcerative inflammation of the mucous mem- 
brane, and periosteum of the middle ear, result in dangerous or 
fatal complications, such as meningitis of the base of the brain 
of the infant ; that of the convexity in older children, abscess 
of the brain, phlebitis, thrombosis of the sinuses, paralysis of 
the face, hemiplegia, mastoid inflammation, caries and necrosis 
of the temporal bones, epilepsy, chorea, stupidity, idiocy, per- 
sistent cough, nausea, or vomiting, or death. 

Should the pedologist doubt, from the list presented of dis- 
eases of the ear, with their possible complications, or fatal cul- 
mination, which are by the aurist to be considered as possible 
causes before a diagnosis in obscure cases is given, even where 
no ear affection has been noticed or considered likely to have 
any bearing upon the condition presented, he will find their 
importance unquestioned, after the observation and experience 
which comes from an extended aural practice. 

General Diseases of the Child in Their Effect upon 
THE Ears. — In the discussion of the various diseases of the 
ear, those which produce more directly an involvement of the 
organ of hearing, such as dentition, the exanthemata, diph- 
theria, typhoid fever, pneumonia, bronchitis, catarrhal condi- 
tions, and other diseases of the nose and pharynx, have already 
been partly considered, and as they bear by far the greater 
causative relation to ear diseases, they demand still further 
attention. The fact should be noted that affections of the 
auricle and the external auditory canal result from eczema, 
or other affections of the skin of the head or face, by an exten- 
sion of the disease through continuity. 

In all cases where an ear affection is noticed, the careful 
consideration of the general condition of the infant or child 
is of the utmost importance in the effort to cure the local 
affection. 

Cerebro-Anemia or Hyperemia may produce more or less 
giddiness, or even marked vertigo, due to circulatory disturb- 
ances in the labyrinth with or without impairment of hearing, 
and is usually associated with disturbance or loss of vision 
from the same cause. When hyperemia is present there is 



GENERAL DISEASES AND THEIR EFFECT. 147 

usually vertigo, with the complaint in older children of noises 
in the ear, with or without visual destructions. Anemic 
conditions more often cause transient loss of hearing with 
faintness. 

Tumors of the Brain, and hydrocephalus, while more common 
causes of eye changes and loss of vision, produce deafness by 
affecting the integrity of the tissues of the internal ear. A 
descending neuritis of the auditory nerve or serous inflamma- 
tion and destruction in cerebro-spinal meningitis, particularly 
of the epidemic form, while frequently affecting both the eyes 
and ears is more likely to impress the ear early in the attack, 
usually during the first few days, and the serous or suppura- 
tive inflammation set up in the internal ear is followed by a 
more or less complete deafness. Cerebro-spinal fever, in con- 
junction with meningitis, the latter taking the lesser promi- 
nence, are the most frequent causes of destruction of the func- 
tion of the internal ear, and present the most common cause 
of deaf-mutism as shown by the census reports. The destruc- 
tion of the nerve which is exhibited in those cases is due to an 
extension of the inflammation from the brain. 

Meningitis, next to cerebro-spinal meningitis is the most fre- 
quent cause of destruction of the hearing function in infancy 
and childhood, and the loss may be due to the complication of 
both middle and internal ears. 

Nephritis in childhood is rarely cause of an aural affection, 
except when the nephritic condition is the cause of lowered 
vitality, then a circumscribed inflammation of the external 
auditory canal may occur, as in the *' cat boils " or small ab- 
scesses of the canal, which appear at any age as the result of 
malnutrition and are often indications of the general con- 
dition. 

Typhoid Fever, bronchitis and pneumonia should be borne in 
mind as causes of aural complications which are not uncom- 
mon and that deafness, or insomnia, or coma may arise from 
ear complications. In the grippe influenzas of the last three 
years the ears have suffered more often from mastoid compli- 
cations than in the common influenzas, which are too often 
the cause of uncomplicated otitis media. During childhood, 
which in our climate is usually limited to the first fourteen or 
fifteen years of life, typhoid fever presents affections of the 
middle ear due mainly to the extension by continuity in cases 
where the catarrhal symptoms are prominent. The mucous 
membrane of the pharynx and naso-pharynx being commonly 
subject to inflammations in all fevers, whether typhoid, typhus, 
remittent or other fevers, the possible ear complications in all 
febrile conditions are to be thought of. While in a general 



148 THE DISEASES OF CHILDREN. 

sense the cases may not be common to the general practitioner, 
the aurist has in his practice to examine, treat and relieve 
many cases of deafness which are complications of these dis- 
eases. 

Intestinal Diseases. — Affections of the alimentary tract have 
little connection in a causative way with aural diseases, except 
in as far as they affect the nutrition of the tissues of the ear, 
and by aggravating a pre-existing naso-pharyngeal condition of 
catarrh cause a middle-ear catarrh, acute or chronic, or a sup- 
purative inflammation with all its possible results, which 
involve the hearing and life of the child. 

Dentition. — During the eruption of the teeth the infant 
often suffers from congestion of the auditory canal and of 
the drum cavity or the eustachian tube, which is accompanied 
by severe pain in the ear, the cause of the crying of the child 
being referred to the swollen gums which are less rarely the 
seat of, although the indirect cause of, the pain. The relief 
obtained in such cases from the application of dry heat to the 
ear enables us to determine the fact that an ear complication 
due to dental irritation is present. When the irritation is pro- 
longed, a slight discharge of pinkish serum from the engorged 
blood-vessels appears upon the pillow, or in more severe cases, 
the external auditory canal fills with pus or muco-pus from 
middle-ear suppuration upon the rupture of the drum-head. 
In all cases attention should be directed to the gums, and 
relief obtained by lancing them whenever it may be deemed 
advisable. 

Syphilis. — In infancy, childhood and adult life the affections 
of the ear from primary syphilis are extremely rare ; an 
occasional case of chancre of the auricle has been reported. In 
the infant the syphilitic infection of it may have been pre-natal 
and the expression of the disease upon the ears that of the 
tertiary stage. 

During childhood a sudden and complete deafness may 
occur as the result of the inherited dyscrasia, which affects the 
internal ear, or in other cases the hearing be slowly lost, owing 
to more gradual disease changes in the middle or internal ear. 

Scarlatina. — Of the exanthemata none cause such frequent 
implication of the middle ear with destructive suppuration, 
acute and chronic, loss of hearing and all the complications and 
sequela which may result, than scarlet fever. Next to men- 
ingitis and cerebro-spinal meningitis, this disease furnishes the 
largest number of cases of deaf mutes ; according to the last 
census report 25 per cent, were caused by scarlet fever. 

Rubeola. — Measles immediately follow scarlatina in order of 
frequency as a cause of aural destruction. The implication of 



GENERAL DISEASES AND THEIR EFFECT. 149 

the throat and naso-pharnyx in both these exanthems, make 
the extension of the disease to the ear very easy, and the in- 
flammation thus produced is followed by destruction of the 
essential portions of the hearing apparatus, and leaves condi- 
tions of chronic ulceration, adhesions in the chain of ossicles, 
and progressive deafness. 

Diphtheria. — Statistics show that diphtheria is a frequent 
cause of deafness, and the direct cause in cases when it is asso- 
ciated with scarlet fever or when the membrane invades the 
upper pharynx. The malignancy of the disease is such that 
when the child becomes deaf from the invasion of the middle 
ear, if it survives the diphtheritic attack, it is likely to become 
permanently deaf, owing to the destruction in the ear and the 
subsequent changes in it which follow. 

Variola. — In small-pox, the impression made upon the ear 
is less marked than that upon the eye, as the pustules are 
rarely if ever found in the ear. Occasionally there is during 
the course of the disease, a middle-ear suppuration, which, 
however, should not be considered the result of direct infection. 

Pertussis. — Whooping cough not infrequently produces ear 
complications, as hemorrhages in the drum cavity, or rupture 
of the drum-head which may occur during prolonged paroxysms 
of cough. A middle-ear catarrh or suppuration is not uncom- 
mon, either during the attack or following it. 

Parotiditis. — Mumps rarely cause an implication of the ear 
during the stage of swelling of the gland, but often after the 
attack has passed, inflammations of the middle ear may follow. 
The internal ear may also suffer loss of function as a result of 
the metastasis of the disease. 

Typhoid Fever. — The mucous membrane of the nose and 
throat are commonly subject to inflammation during typhoid, 
typhus, remittent or other fevers ; for this reason middle-ear 
complications are frequently presented. Occasionally one or 
both labyrinths are affected by cell infiltration during the 
course of the fever which may result in temporary or permanent 
deafness. 

Diseases of the Heart are scarcely ever known to produce 
any direct effect upon the ears of children. 

Diseases of the Central Nervous System cause loss of hearing 
more or less complete from affections of the internal ear. In 
the brain, changes in the cortex present such unique phenom- 
enon as deafness for certain words, or "word deafness." 

Diseases of the Sexual System. — Those changes in the general 
system occurring at puberty, as a rule produce less affection of 
the auditory than those of the visual organs. It is rarely that 
we find at puberty an appreciable effect of the change in the 



150 THE DISEASES OF CHILDREN. 

sexual system upon the ear; even when noticed, usually caus- 
ing only an aggravation of a tendency to ear disease which had 
previously existed. 

Injuries of the Ear. — The auricle and outer portion of the 
canal are rarely the seat of direct injury, except those which 
result from the attempts to remove foreign bodies from the 
ear. At times an insect may find its way into the infant's ear 
while sleeping upon the ground, or even in its crib. The diag- 
nosis of the cause of the infant's discomfort cannot always be 
readily arrived at, but in the absence of other affections which 
account for it, a glance into its ear may reveal the presence of 
an insect ; then a few drops of water, oil, or any bland fluid in- 
stilled into the ear, will at once quiet the child by drowning 
the insect, which soon appears in the fluid at the outer portion 
of the canal. 

Occasionally we are called upon to treat a punctured wound 
which follows the introduction of some sharp-pointed stick or 
instrument. 

In infancy, owing to the more horizontal position of the drum- 
head, it escapes injury unless much force is exerted. Injuries 
of the deeper portion of the ear are apt to be followed by men- 
ingeal inflammation arising from the trauma. 

During childhood, foreign bodies of all kinds are frequently 
put into the ear by the child or its playmates. The size is al- 
ways less than the caliber of the meatus and this fact should 
always be kept in mind. The child never pushes it so far in 
that with intelligent care, it cannot be readily removed ; in the 
majority of cases, when foreign substances are in the canals, 
changing the position of the head, by placing the child on a 
table with the head extending beyond it and the ear containing 
the foreign body directed towards the floor, a slight pulling 
downward of the ear, thus straightening the canal, results in the 
falling of the body by the force of gravity to the floor. If this 
fails, then no effort should be made to remove it, without first 
having ascertained its exact nature and position under a full 
illumination. Even then it is better to use the syringe and 
water than to attempt its instrumental removal except in the 
most skillful hands. In the majority of cases, where foreign 
bodies have been placed in the ear, the danger is always greater 
of injury to the ear from the misguided efforts at its removal 
than from the foreign body itself. Ordinarily, an object put in 
the ear, unless pressing upon the drum-head, which occurrence 
is very rare, except as the result of an attempt to remove it, 
may remain there for years without other disturbance than a 
partial or complete loss of the hearing in the stopped ear. 



INyURIES OF THE EAR. 151 

Pebble-stones, seeds of all kinds, sufficiently small to pass into 
the canal, deciduous teeth, shoe-buttons, cork, pieces of cloth, 
wads of cotton, and various other substances have, in the writ- 
er's experience, been removed from the ears, after having re- 
mained there for weeks, months and many years without occa- 
sioning any disturbance except that of defective hearing. It 
has been the good fortune of the aurist to relieve what has 
appeared to be serious neuroses; but when, in the absence of a 
satisfactory explanation, their cause has led to the examination 
of the ear where deafness of one ear had been noticed and the 
removal of a foreign substance, which, pressing upon the walls 
of the canal occasioned the reflex symptoms, removed all dif- 
ficulty. 

Tumors of the ear or malignant disease are so rare in child- 
hood that they need no discussion here. 



PART" III. 

DISEASES OF THE DIGESTIVE ORGANS. 



CHAPTER I. 
GENERAL CONSIDERATIONS. 

Diseases of the digestive apparatus are exceedingly com- 
mon in infancy and childhood, and only the greatest care in 
the management of the food, the clothing and the hygiene 
of the nursery can avoid them. Even under the most favora- 
ble circumstances and when every care has been exercised, 
vicissitudes of climate, atmospheric changes, impurities in 
food which have eluded all vigilance and other factors which 
the greatest foresight cannot eradicate, render disturbances 
of this part of the organism among the most frequent that 
the physician has to deal with. Whoever has read the pre- 
ceding pages must have recognized the difficulties encountered 
by one endeavoring to meet the nutritive wants of a young 
infant, whose powers of assimilation are at best but feeble and 
who may possess peculiarities or idiosyncracies which experi- 
ment and repeated trials alone can render intelligible. The 
diseases and disturbances of function which we are about to 
consider are usually readily recognized and generally at their 
beginning easily remedied by intelligent treatment. They can- 
not, however, be neglected ; for, trivial as they may seem in 
their incipiency, they are liable to become chronic and obstinate 
or even fatal. A timely recognition of the malady, a true un- 
derstanding of its pathology, and a judicious selection of reme- 
dies are imperative. 

It will be found, especially in hand-fed infants, that a change 
of diet is frequently an essential part of the treatment. In 
cases where vomiting or diarrhea is a prominent symptom, it 
will be advisable for a day or two to suspend cow's milk either 
partly or wholly, and to substitute cream therefor. In obsti- 
nate cases of this kind, in which the milk is thrown up curdled, 
or passed undigested in the stools, raw-meat juice, spoken of in 
another chapter, or bread jelly should not be forgotten. The 
(152) 



SIMPLE OR CATARRHAL STOMATITIS. 153 

gelatin food of Dr. Meigs is another food that meets the special 
wants of some of these cases. 

Oftentimes a slight change in the customary aliment is 
sufficient to set matters to rights ; but often, again, the physi- 
cian will be sorely puzzled to find the exact food that will fit 
the case. Nothing but watchful and persistent care will insure 
success, and in the matter of remedies the closest study of both 
symptoms and drugs will be necessary. 

It should be clearly borne in mind that vomiting in infancy 
does not always have the significance that it carries with it in 
adult life. Indeed, vomiting or regurgitation of food in infancy 
may be simply due to too frequent nursing or overfeeding and 
may have no pathological significance whatever. It occurs 
without nausea and without effort. The size of the stomach, as 
we have already pointed out in our introductory chapter, is rel- 
atively small — holding at the age of two months only about 
four ounces, and at twelve months about ten ounces — and if 
this capacity for food be exceeded, as it often is by a healthy, 
vigorous child, the vomiting is simply the overflow which is 
over and above the stomach's needs. The position of the 
stomach, moreover, is nearly vertical and the absence of the 
gastric fundus makes vomiting under these circumstances a 
matter of great ease. The milk thus ejected is unchanged, or 
if it has been retained for some moments the casein may be 
somewhat coagulated. In either event there is little harm from 
its being thrown up ; in fact, it is a salutary phenomenon, for 
this excess of food, if retained, would undergo fermentation and 
give rise to irritation either of stomach or bowels. 

Vomiting, however, when attended by emaciation or loss of 
vivacity, or if frequently repeated when there has been no 
excess of feeding, should always arrest attention and its cause 
be ascertained. It may be the first symptom of gastric irrita- 
tion or of incipient meningitis. 

STOMATITIS. 

There are several varieties of inflammation of the mouthy 
which are very common among infants and children, the mild- 
est of which is known as, 

Simple or Catarrhal Stomatitis. — This form is most 
commonly met with in hand-fed babies, before the completion 
of first dentition, and indeed is most frequent under the age of 
one year, and hence is often described by the laity as ** nursing 
sore mouth." It may sometimes be found in infants at the 
breast, who are, to all appearances, in otherwise good health. 



154 THE DISEASES OF CHILDREN. 

More often, however, it will be found that the inflammation of 
the mouth is but the visible symptom of a derangement that 
extends to the stomach, if it does not originate there. It is 
frequently encountered in the course of any of the constitu- 
tional diseases, and usually accompanies or follows the eruptive 
fevers, and is a part of them. Anything which lowers the tone 
of health may lead up to it, while teething is a very common 
cause. In these cases, the gum over the advancing tooth first 
becomes inflamed, and from this as a starting-point the inflam- 
mation may extend over a portion or the whole of the buccal 
surface. When due to teething, the inflammation is, as a rule, 
partial rather than general. 

Symptoms. — Inflammation of the mouth, from whatever cause, 
is indicated by increased redness, and more or less thickening 
of the mucous membrane, and by increased functional activity 
of the mucous follicles. There is more or less augmentation of 
the heat of the mouth, and pain is experienced when the in- 
flamed parts are touched. In some cases the gums become 
swollen and spongy, and bleed easily if rubbed or pressed upon. 
The soreness in these cases is the most prominent symptom 
and is sometimes so great as to materially interfere with suction. 

The tongue is generally coated with a light fur and the sali- 
vary secretion is more or less increased — sometimes so much so 
as to cause dribbling from the mouth. Bleeding from the gums 
is not uncommon in these cases; but except in poor and neg- 
lected families is rarely allowed to reach such a stage. The in- 
fant is restless and fretful, and apt to cry whenever it attempts 
to nurse, from the pain experienced in closing on the nipple. 
There is little or no general fever ; and, except in cachectic in- 
fants, or those suffering from some grave co-existing disease, is 
not at all of a serious nature. It usually yields readily to the 
simplest treatment ; but in some instances, if neglected, it may 
terminate in one of the more severe forms, such as the ulcerous 
or aphthous. 

Treatment. — The first duty of the physician is to ascertain, 
if possible, the cause of the stomatitis and to remove or cor- 
rect it. Bathing the mouth with a soft linen rag wet in cold 
water should often be resorted to, as it cools the mouth and 
constringes the relaxed and swollen tissues. If the gums are 
swollen from teething, it is quite proper to lance or scarify them, 
as directed in the chapter on teething. Borax is a very useful 
local remedy, either with honey; or glycerine and water in the 
proportions of one part borax to three of honey ; or a drachm 
of borax to an ounce of glycerine and water. A weak solution 
of alum is also useful. One of these preparations frequently 
applied, with greater attention to washing the mouth and gums 



ULCEROUS STOMATITIS. 155 

after each feeding, is usually all that is necessary. The disease 
is so slight in this simple form that no remedies internally ad- 
ministered are necessary. 

Ulcerous Stomatitis. — Sometimes a simple stomatitis, 
instead of going on to recovery, quickly eventuates in an ulcer- 
ous condition of greater or less extent. 

This ulcerous condition, however, when present is always 
grafted on, or succeeds to, the simple form of stomatitis. The 
ulcers commence as small white or yellow points and consist 
■of plastic exudation under the epithelium. This exudation 
produces a slight elevation or prominence of the mucous mem- 
brane and causes an ulceration of it. The inflammation usually 
begins upon the gums and extends along and upon the buccal 
surface. Some of these white points unite and thus enlarge 
the affected area. This extension is irregular, and in some 
•cases forms large patches of ulceration. There is no uniform- 
ity as regards the size or shape of the ulcers. In the folds of 
the buccal membrane they are apt to be elongated, while in 
other situations they may be round or oval. As disease pro- 
gresses, fresh ulcerations appear, until in some cases a good por- 
tion of the mucous membrane of the mouth may become in- 
volved. It is no unusual thing to find simple inflammation in 
one portion of the mouth and this ulcerous form in another. 
If the disease is severe, there is considerable swelling about the 
margins of the ulcers and the breath is sometimes very fetid. 
As soon as improvement begins the swelling subsides, the ulcer- 
ous surface becomes more clear and presents a granular ap- 
pearance. After a time the mucous membrane is reproduced, 
but the new membrane for a considerable period remains of a 
darker hue than the adjacent surface. Recurrence of attack 
is very common. Such cases of the disease are rare in private 
practice, but in hospitals it prevails extensively and apparently 
in epidemics. 

Causes. — Acidity of the stomach is a prime cause in most 
cases. Personal uncleanliness, poor food, damp and un- 
wholesome apartments — anything, indeed, which reduces the 
system and produces a cachectic state conduces to its develop- 
ment. It frequently follows the essential fevers and intestinal 
inflammations, and in the entero-colitis of infants it is apt to 
form a protracted and obstinate complication. Its prevalence 
in the wards of a hospital, where several cases occur together 
or consecutively, has been thought by some to indicate its 
contagiousness. But its contagious character is by no means 
established. In private practice it exhibits no such tendency, 
and it is quite as reasonable to suppose that, in multiple cases. 



156 THE DISEASES OF CHILDREN. 

there is a common exposure to the same malign influences, 
just as a whole household may be exposed to malaria and be 
seized with intermittent fever. We have already spoken of 
dentition as a frequent cause of simple stomatitis, and the 
ulcerous form is the same thing, carried a step further, viz., to 
the stage of ulceration. 

Symptoms. — The symptoms in ulcerative stomatitis are more 
severe than in the simple form. There is more fever, more 
fretfulness, more salivation and increased tenderness of the 
parts affected. Drinks, unless lukewarm and very bland, are 
taken only with pain and difficulty. Both heat and cold are in- 
tolerable. If the ulceration is on the gums or lips, the infant 
nurses with reluctance and cries with pain when the attempt is 
made. It should be stated, however, that this form of the dis- 
ease is not so common among infants as among children. Oc- 
casionally, though rarely, the submaxillary glands are tumefied, 
hard and tender. The breath is always more or less affected, 
and in some cases is exceedingly offensive. 

Prognosis. — The prognosis is always favorable, unless the 
patient is in a decidedly cachectic condition, or a serious co- 
existing disease be present. Under these circumstances it may 
be protracted. When the ulcers are small and the inflamma- 
tion of limited extent, the course of the disease is shorter and 
more easily managed than when the ulcers are large and the 
inflammation more extensive. 

Treatment. — In the ulcerous, as in the simple variety, much 
relief is experienced by the use of various soothing applications, 
applied locally. If the child is old enough to use a mouth 
wash, a very good one is permanganate of potash, one grain to 
the ounce of water. Another wash is highly recommended, 
viz.: hydrastis, which may be used, one-half diluted with 
water. For young infants, who cannot, of course, gargle their 
mouths, there is no better application than the borax and 
honey, spoken of in the last section, applied with a camel's-hair 
pencil over the affected area. This should be done several 
times daily. As for internal remedies, the fact that calomel, 
when given to children, produces a disease of the mucous 
membrane of the mouth that is indistinguishable from ulcerous 
stomatitis, would naturally lead us to look to this remedy in a 
mild form, or at least to some preparation of mercury as the 
true simillimum. Experience has amply borne out the theory, 
and placed mercury at the head of the list of homeopathic 
remedies in this affection. We have found the mere. sol. h. 
3x eminently satisfactory given in trituration, a powder of per- 
haps two grains every three hours. This preparation of 
mercury we have used with prompter effect than any other 



FOLLICULAR STOMATITIS. 157 

preparation of this drug. Some years ago we had a most 
obstinate and severe case of stomatitis ulcerosa, in our Free 
Dispensary, that resisted all treatment for several weeks. It 
occurred in a girl some eight or nine years of age. The 
mucous lining of the right cheek was honeycombed with 
ulceration. She was in fair general condition. Her breath 
was horribly offensive. She had been to other dispensaries 
previously without benefit. She was given several remedies — 
mercurius sol. 3x, among others — without the slightest im- 
provement, when it occurred to me, that, as mercurius was so 
clearly indicated it might be well to try the remedy in a higher 
attenuation. All other remedies were discarded, as well as all 
local treatment, and she was given twelve powders of two 
grains each, mere. sol. 30th, to be taken every four hours. In 
a week she was greatly improved and the remedy continued. 
In another week she was discharged cured. Since this case 
improved so much more rapidly under the higher attenuation 
of mercury — indeed, she did not improve at all under the low — 
we have frequently employed this potency of the drug with 
success. 

The following indications will assist in the selection of the 
remedy for the particular case in hand : 

Mercurius. — Extensive ulceration, fetid breath, copious flow 
of saliva, tumefaction of submaxillary glands, ulcerated surface 
bleeds. 

Arsenicum Alb. — Great exhaustion, slight salivation, co-exist- 
ing diarrhea of watery and painless character. 

Baptisia. — Considerable fever of hectic character ; marked 
general cachexia; great fretfulness and restlessness. 

Arum Triph. — Infant refuses drink and cries when it is 
offered ; saliva acrid and excoriates the lips, causing sores on 
lips, chin and cheek. 

Nitric Acid. — Mouth dry and hot ; gums swollen, spongy 
and bleeding. Other symptoms similar to preceding remedy. 

Follicular Stomatitis— Aphtha. — The aphthous form 
of stomatitis is very different from those forms that have 
just been described, but its features are so distinct that there is 
very little likelihood of confusion. Many writers include all 
forms of inflammation of the mouth under two heads, viz., 
aphthae and thrush. 

The word " aphthae " itself is confusing, for it is derived 
from a Greek word meaning " to inflame." It has come, how- 
ever, by general consent, to signify a form of stomatitis charac- 
terized by small, round ulcers, which run an acute course, and 



158 THE DISEASES OF CHILDREN. 

are so different in cause and character as to be worthy of a dis- 
tinct name and description. 

Causes. — Aphthae occurs in children between the ages of two 
and six years, i. e., after the suckling period, and is apparently 
more often than otherwise due to errors in diet ; such, for ex- 
ample, as the too free indulgence in pastry and sweets generally. 
It may, however, like the other forms of stomatitis, be due to a 
deranged state of health, such as may be left by scarlet fever, 
measles, whooping cough or prolonged gastro-enteritis. It is 
most common in springtime and autumn, when climatic changes 
are apt to depress the system. 

Symptoms. — Aphthae consists of a number of small, round 
ulcers, varying in size from a pin's head to a pea, usually well 
defined and clear cut, of round or oval shape, and are situated 
most frequently on the lining membrane of the lower lip ; but 
they may be seen in the furrow between the gum and the cheeks, 
and occasionally on the latter. They are rarely found on either 
the palate or the gums. They are quite superficial and are white 
or yellowish-white in color. They are raised above the level of 
the surrounding tissue and are bordered by a bright or livid ring 
of inflamed membrane. They have a striking resemblance to a 
pearl or bead beneath the mucous membrane, through whose 
transparent wall they have a glistening appearance. As they 
occupy the site of the muciparous follicles, they give the 
name of "follicular" stomatitis to this variety. They are espe- 
cially vesicular in character, and soon after being formed the 
vesicle ruptures, leaving a shallow ulcer with a yellowish-gray 
surface, which heals in the course of a few days, while fresh 
follicles are forming in the near vicinity. While these pearly 
spots are rarely seen upon the gums themselves, their edges are 
prone to be inflamed and more or less gingivitis is quite common. 
These ulcers are exquisitely painful when touched, much more 
so than the inflamed surface of the other forms of stomatitis. 
This is a distinctive feature. When the ulcers are situated on 
the tongue, they are extremely tender and often prevent the 
child from eating for days together. There is an increased flow 
of saliva, but not to the extent that occurs in other forms of 
stomatitis ; and there is no offensive odor to the breath. Some- 
times two or more ulcers coalesce and make quite an extensive 
sore, but this is very rare. More often the ulcers are solitary, 
leaving patches of normal mucous membrane between them. 
Their isolated character, their extreme tenderness and sharply 
defined outlines, together with their pearly-gray appearance, 
are sufficient to distinguish them from any other affection of 
the mouth. 

There is generally an absence of any but the most trifling 



THRUSH. 159 

symptoms of general disturbance, although in some cases there 
may be slight fever, furred tongue, thirst and other symptoms 
of constitutional disturbance. When symptoms of a graver 
character than those here indicated are present there is some 
co-existing malady, to which the aphthae is secondary. 

Prognosis. — This is always favorable, so far as the aphthae, 
independently considered, is concerned. When taken in con- 
nection with other and more serious conditions of health, they 
may have themselves a gravity not otherwise possessed. 

TrcatineJit. — In this form of stomatitis the mouth should be 
washed out often with chlorinated water or listerine. A good 
wash if composed of carbolic acid or boric acid — three or four 
grains to the ounce of water. 

When the aphthous patches are so tender as to prevent eat- 
ing, they may be brushed over with a flve-per-ct. solution of 
cocaine before food is taken or a decoction of marshmallow or 
mucilage of quince. The action of these is stated by Dr. All- 
chin to be essentially protective to the raw, painful surface, as 
well as being somewhat astringent. 

The remedies for internal use are mainly the same as those 
heretofore spoken of in the other forms of stomatitis. Mer- 
curius stands at the head of the list. In addition to the reme- 
dies already mentioned, consult 

EtJiiisa. — Stools undigested ; much crying as if from colic ; 
profuse salivation or its opposite, great dryness of mouth. 

Bryonia. — The mouth is usually dry wath thirst ; lips dry and 
parched, rough and cracking ; child refuses to take the breast, 
but W'hen once its mouth is moistened, and it is fairly at work, 
it nurses well. 

THRUSH. — (MUGUET ; SPRUE ; PARASITIC APHTH/E.) 

Character. — This is the form of stomatitis most common in 
early infancy. It differs radically from the other forms of sore 
mouth which we have been considering, in cause, nature and 
gravity. It consists in the growth and development upon the 
mucous membrane of a peculiar fungus, known formerly as the 
oidiiim albicans^ but latterly as saccharoniyces myoder^na. 

Etiology. — Just how this fungus or its spores gain an entrance 
into the mouth of a nursing babe is uncertain, but it is alto- 
gether probable that it is through the contact with the mother's 
nipple. Bacteriologists regard the fungus as identical with that 
which turns milk sour, but this point is not fully determined. 
As the disease is far more prevalent among bottle-fed infants 
than among those nursed at the breast, it is more than likely 
that the contagium is communicated through the bottle or the 



160 THE DISEASES OF CHILDREN. 

spoon used in feeding. The milk itself may be a source of 
infection. 

A curious feature of the matter is the fact that in a normal 
condition of the mucous membrane, this fungus will neither 
grow nor develop. It must have a diseased membrane, or at 
least one not in a perfectly healthy condition, before it will take 
root and flourish. The extent to which it does develop may 
be taken as a fairly accurate index as to the extent to which 
the nutrition of the mucous surface is perverted. An acid state 
of the secretions favors its development. It cannot thrive in 
an alkaline medium. Milk curd remaining in the mouth, even 
in the smallest particles, speedily turns sour and forms a fitting 
soil for its propagation. Strictly speaking, thrush is not a 
special form of stomatitis, but requires a preceding stomatitis 
for its development. Some derangement of the system, by 
which nutrition is impaired, and the normal state of the mu- 
cous membrane altered, is an essential pre-disposing element. 

Symptoms. — Thrush appears in the mouth, first as small, 
pearly-white patches, closely resembling a bit of milk curd. 
These white spots or patches are of varying sizes, from a pin's 
head upward. They are most commonly found on the buccal 
surface, but occasionally may develop in the pharynx, esopha- 
gus, or other portion of the digestive tube. It is quite prone 
to add itself as a complication of gastritis or entero-colitis. In 
the latter case it may extend as far as the anus. It does not 
affect the nares, the larynx or the bronchial tubes. The first 
stage of the disease, as above indicated, is that of simple in- 
flammation. On this inflammation the point or patch is devel- 
oped, and is first white and afterward turns faintly yellow. 
The center of each is more elevated than the margin. They 
are easily detached by a little force, but are quickly reproduced 
again. Their highest elevation is not more than a line above 
the surface. They tend to spread with great rapidity, so that 
a single point, at first scarcely visible, may extend in three or 
four days so as to cover the greater portion of the mucous 
lining of the mouth. From the first there are the usual symp- 
toms accompanying the simple form of stomatitis, such as rest- 
lessness, fretfulness, slight fever, and pain when nursing is 
attempted. There is not the same amount of salivation as in 
other forms of stomatitis, the mouth being rather dry and hot. 
There is no fetor of the breath. In severe cases, the intestinal 
tube is always affected and the infant has thirst, loss of appe- 
tite, vomiting and diarrhea. Rapid emaciation follows as a 
natural consequence ; and if the disease is not arrested, a state 
of dangerous prostration may be speedily reached. 

Prognosis. — The duration of thrush varies according to its 



GANGRENE OF THE MOUTH. 161 

intensity, and the favorable or unfavorable condition of the in- 
fant. Under favorable conditions it may be cured in three or 
four days, but under unfavorable conditions it may last for 
weeks, unless death supervene sooner. When thrush occurs 
in connection with gastro-enteritis, the mortality is very great ; 
and occurring in the course of any exhausting disease it is an 
unfavorable omen. As it is most common during the first few 
weeks of life, when the reactive powers of the system are 
feeble, the prognosis is correspondingly doubtful. In itself, 
however, thrush is not a serious malady. Its grave aspect is 
due to the low state of vitalit)^ or the co-existing derangements 
with which it is associated. 

Treatment. — From what has been said regarding the cause 
and nature of thrush, the first object of treatment should be to 
correct the acid condition of the mouth which favors the 
growth and spread of the fungus. This can only be accom- 
plished by the most scrupulous cleanliness, and by repeatedly 
washing the mouth with some alkaline lotion, such as borax or 
sulphide of soda. One or the other of these lotions should be 
used after each meal, and care should be taken to reach every 
point of the infected mucous membrane. Attention should be 
given to the general health, and the medication should be 
adapted to the totality of the symptoms, of which the obvious 
thrush may be but a minor factor. For this reason, the remedies 
which we have already named as suitable for other forms of 
stomatitis, or which might be considered as indicated, were the 
malady a purely local one, must be abandoned for such drugs as 
will reach not only the inflamed mucous membrane of the 
mouth, but extend their influence to the whole digestive tract. 
In other words, constitutional remedies are called for, to correct 
the constitutional dyscrasia underlying the local symptoms. 
Mercurius is one of those deep-acting remedies that will often 
be found to cover the entire case. Calcarea carb. is another. 
Besides these consult carto. veg. china, and arsenicum. 

GANGRENE OF THE MOUTH. — (CANCRUM ORIS.) 

Defijiition — Frequency. — The term " cancrum oris," by 
which this disease is sometimes known, is apt to mislead one 
to suppose it the same as " canker sore mouth," by which 
term the laity are wont to designate the aphthous form of 
stomatitis. The latter, as we have seen, is generally a trifling 
malady and attended with little danger, while the former is 
among the most fatal of early life. It is fortunately a very 
rare disease in this country, and even among the poor and 
densely crowded districts of London, it is met with but rarely. 
D. C— 11 



162 THE DISEASES OF CHILDREN. 

At the East London Hospital for Children during seven years 
— from 1 88 1 to 1887 inclusive — out of a total number of six 
thousand three hundred and sixty-four admissions, there were 
only five cases, and in the Hospital for Sick Children, Great 
Ormond St., during thirteen years ending in 1888, with a total 
admission of nearly thirteen thousand patients, there were but 
six cases. We have no statistics of the disease in this country, 
but can state that during the past seventeen years, not a single 
case has been seen at the Central Free Dispensary in this city 
(Chicago), and in a private practice extending over nearly 
thirty years, we have seen but one case. It is usually of 
secondary origin and consists of a rapidly progressing necrosis 
of the cheek or gum, which is usually fatal, and is recovered 
from only with permanent loss of tissue. It seems to be much 
more common among females than males, and more frequent 
between the ages of two and five years than subsequently. It 
is common to the low-lying, damp countries, such as Holland 
and parts of Sweden, where it is almost endemic. It is not 
contagious. Some previous disease, which has left the general 
health in an impaired condition, or some mal-hygienic influence 
seriously lowering the standard of vitality, is necessary for its 
production. For some unexplained reason, more than one- 
half of the recorded cases have followed closely after measles. 
A few cases have been observed to follow scarlet fever and 
the other eruptive fevers. Simple or ulcerous stomatitis often 
precedes it. 

Anatomical Characters. — The parts most subject to attack 
of gangrene are the inside of the cheek, which first becomes 
inflamed, then thickened and indurated. This induration ex- 
tends rapidly and the dark hue of gangrene appears, followed 
soon by sloughing of the portion, the vitality of which is lost. 
As the disease progresses it does not incline to attack the 
blood-vessels, but leaves them exposed while it burrows 
amidst the softer tissues till it reaches and penetrates the skin 
of the cheek outside. At the same time it extends downward 
to the deeper-seated structure of the jaw, where it loosens one 
or more of the teeth. If its progress be not arrested, it attacks 
the periosteum of the maxillary bone, destroying the gum and 
teeth and denuding the alveoli. Wherever it reaches, the 
tissues are irreparably destroyed. 

Symptoms. — The first symptom to be observed is in the mouth, 
where a point of inflammation presents all the visible signs of 
simple stomatitis. Very soon, however, there ensues a thick- 
ening of the surrounding tissue. The mucous membrane pre- 
sents a dark-red appearance for the distance of a few lines 
beyond the point of gangrene, which point marks the seat of 



GANGRENE OF THE MOUTH. 163 

the initial lesion. This dark-red portion covers tissues which 
are inflamed and indurated and about to become gangrenous. 
As the disease approaches the surface of the cheek, a livid cir- 
cular spot is noticeable on the skin corresponding to the al- 
ready necrosed portion of the mucous membrane within the 
mouth. The tongue is usually swollen, but moist ; there is lit- 
tle or no fever, and the indications of suffering are not at all in 
proportion to the gravity of the disease which is in progress. 
As gangrene is rarely, if ever, a primary affection, its symptoms 
are not easily separated from the general pathological state 
which accompanies it. There is progressive prostration as the 
disease advances. The body and limbs emaciate and the eyes 
are hollow and the lids edematous. Sometimes the child is 
fretful, at others dull and indifferent. The pain is never as 
great as in some forms of stomatitis, which are devoid of dan- 
ger. If the cheek is perforated, it interferes with alimentation 
to such a degree that the appearance of the child becomes piti- 
able. The saliva flows from the mouth either pure or mixed 
with blood and offensive matter. 

Except in very mild cases, there is a distinctively gangrenous 
odor. There is usually great thirst, and the appetite, though 
sometimes poor, is often good throughout the entire course of 
the disease. There is no vomiting, nor are the bowels affected. 

Prognosis. — The majority of children affected with noma die, 
either from exhaustion or from fatal hemorrhage, which results 
from the destruction of continuity in one of the blood-vessels. 
In many cases, however, which reach a fatal termination, there 
is no hemorrhage, in consequence of coagulation in the vessels. 
The prognosis is materially affected by the amount and nature 
of the cachexia associated with it. If it occurs as a sequel to 
a disease which has materially sapped the vigor of the patient^ 
and co-existing symptoms indicate a serious condition of mal- 
nutrition, the outlook is obviously poor; but if the general 
health is in a fair condition and assimilation is not hopelessly 
impaired, there may be a chance to arrest the gangrene before 
it has reached a necessarily fatal stage. If the disease has in- 
volved the maxillary bone, recovery takes place with the per- 
manent loss of teeth, and the patient may lose the free use of 
the jaw. The separation of necrosed bone in such cases is 
slow and tedious. 

Treatment. — As gangrene of the mouth is pre-eminently a 
disease of debility, the most obvious necessity of treatment is 
to bring about, if possible, the most rapid restoration of the 
general health. All anti-hygienic influences must be removed, 
and the most nourishing food given. Old-school writers recom- 
mend ferruginous preparations and the bitter tonics, such as 



164 THE DISEASES OF CHILDREN. 

quinia, quassia, etc. Cod-liver oil is also recommended. The 
nature of the disease is such, that a prompt arrest of the de- 
structive process is most desirable, and for this purpose, some 
escharotic is a necessity. M. Taupin advises, after removing a 
considerable portion of the gangrenous tissues with scissors, 
the application of strong muriatic acid, and when the slough is 
detached, of dry chloride of lime. 

Dr. Coates, in the Children's Asylum, uses the following 
formula, which is indorsed by others who have used it : 

^ Cupri sulph 3 ii« 

Pulv. cinchona S ^^* 

Aqua S ^v- Misce. 

This is to be applied twice a day very carefully to the full 
extent of the ulcerations and excoriations. *' The addition of 
the cinchona is only useful by retaining the sulphate of copper 
longer in contact with the edge of the sore." Dr. Coates has 
also found a solution of the sulphate of zinc, 31 to an ounce of 
water, by itself or combined with tincture of myrrh, to be 
useful. 

The odor which comes from the gangrenous mass is not only 
very offensive to those who are associated with the case, but 
has a deleterious effect upon the child, who is constantly inhal- 
ing it. Some antiseptic and deodorizer is therefore essential, 
the best of which is a strong solution of permanganate of potass., 
with which the sore may be bathed as often as necessary. Lis- 
terine is also very useful for this purpose. 

The remedies which are most likely to be useful in this affec- 
tion are arsenicum, thuja, mercurius and lachesis. The best 
preparation of mercurius for this affection is mere, dulcis. The 
indications for arsenicum have already been given. Lachesis 
is characterized by fetor of breath, gangreneous ulcerations, 
black and humid gangrene, salivation, and hemorrhages. The 
pathogenesis of thuja is such as would suggest its usefulness 
in this disease, but we are not aware that it has ever been thus 
employed. Phosphoric acid is a remedy likely to be service- 
ble in cases having painless diarrhea and in children who are 
syphilitic. It is all the more indicated if the gangrene follows 
measles in children with inherited taint. 



CHAPTER II. 

ESOPHAGITIS. 

Inflammation of the esophagus occurs but rarely in in- 
fancy and childhood, but often enough to require a brief con- 
sideration. 

Causes. — It occurs most often in bottle-fed babies, and is due 
to giving food either too hot or too cold. Foods also which 
give rise to acidity of the stomach with attendant eructations 
of irritating gases may give rise to it. Occasionally it is due to 
an extension of stomatitis, either the simple or ulcerous form, 
or of thrush from the mouth into the gullet. The accidental 
swallowing of acrid substances, such as acids or alkalies, may 
be the cause, the irritant producing stomatitis and gastritis at 
the same time. 

Anatomical Characters. — The inflamed surface of the esoph- 
agus does not always present a uniform appearance. The in- 
flammation, instead of being spread over the mucous membrane 
with equal intensity, is more apt to show itself in streaks or 
patches. Dr. J. Lewis Smith says that he has frequently 
observed at autopsies a greater degree of inflammation in the 
lower than the upper half of the esophagus, even in cases where 
the infant had stomatitis at the time of death. 

Symptoms. — The symptoms of esophagitis in infants are not 
very clearly defined. There is pain when efforts at deglutition 
are made, but the pain is not intense, nor are there other indi- 
cations of any peculiar distress. Vomiting is not common — at 
least, there is no vomiting that can be referable to the esopha- 
geal inflammation. As the disease is generally an accompani- 
ment or an extension of stomatitis downward, or of intestinal 
inflammation upward, its symptoms are generally masked by 
those of the primary disease. 

Treatment. — When the latter is the case, remedies ad- 
dressed to the primary affection are the proper ones for 
esophagitis, and no special medicines are required for its cure. 
Attention should be given to the diet, however, and all foods 
should be excluded from the dietary which are likely to 
cause acidity of the stomach or which conduce to indigestion 
in any form. 

(165) 



166 THE DISEASES OF CHILDREN. 

GASTRITIS. — (gastric CATARRH.) 

Inflammation of the stomach is not common among infants 
nursed at the breast, although nursing women may, by errors 
in diet or by reason of ill-health in themselves, or from 
other causes, convey to the nursling a congestion of the 
mucous follicles of the stomach of more or less serious char- 
acter. Among children who are well born and have a good 
general development at birth, slight derangements in the 
condition of the mother or wet-nurse do not produce appre- 
ciable symptoms of indigestion, as a rule. There are ex- 
ceptions to this, however. Billard and other observers have 
seen cases of acute gastritis in young infants who had taken 
nothing of an irritating character into the stomach. In 
connection with inflammation, either of the mouth or of 
the intestines, gastritis is by no means uncommon. In such 
cases the trouble arises from extension of the primary dis- 
order along the mucous tract. Undoubtedly the most com- 
mon form of indigestion in infancy is that which, at first at 
least, involves function only, and does not necessarily imply 
a pathological change in the stomach itself. It would be 
wrong to include such cases in a consideration of the sub- 
ject of inflammation of the stomach, and we shall consider 
them in the succeeding section, under the head of Congenital 
Dyspepsia. 

The term gastritis is here restricted to those cases of stomach 
disorder wherein there is not merely a slight indigestion, but 
other evidences of impairment of function due to organic lesion. 
This lesion may be, and often is, slight in its incipiency ; but it 
is sufficient to retard growth and render its subject peevish, 
fretful and sick, and if not arrested it may easily and quickly 
compromise life itself. 

Causes. — Defective feeding is by all means the most prolific 
cause of gastric catarrh in infants, and it is amazing what serious 
consequences may result from a very trifling departure from 
strict physiological requirements in the matter of food. In 
nurslings, if the milk of the wet-nurse is a little too old, or if the 
infant is put to the breast too often, a condition of irritability is 
set up which ultimately results in inflammation or gastric 
catarrh. Insufficient clothing may result in a sudden check to 
the cutaneous circulation, or too rapid cooling of the body after 
being heated in play may cause a congestion of the mucous 
membrane of the stomach, when a comparatively trifling error 
in diet, which under other circumstances would do no harm 
whatever, may now result in a derangement of serious character. 
A neglect of sanitary precautions, such as air, light, exercise and 



GASTRITIS— Sl'MPTOMS. 167 

ventilation ; the depressing influences of dentition and the acute 
ailments and specific fevers, so common in childhood ; any or 
all of these may reduce the nervous force and bring about 
derangement of the complicated functions of digestion. An 
inflammation of considerable extent and serious type may be 
produced by the infant swallowing liquids which are too hot or 
too cold, or containing spices or other irritants, which inflame 
the esophagus first and the stomach afterward. We once saw 
a case of acute gastritis in an infant less than a year old caused 
by tartar emetic in the third decimal trituration. The attack 
lasted for some days and was attended with constant vomiting 
and retching. 

Symptoms. — The first noticeable departure from a state of 
health in cases of gastritis is shown is loss of apetite with vom- 
iting of ingested food or drink. Nausea, as evidenced by gag- 
ging, is an early symptom and this is soon replaced by persistent 
throwing up of everything taken into the stomach. If milk is 
taken, it comes from the stomach curdled. The vomiting is 
not ended with the ejection of food ; it continues until mucus 
and perhaps bile are expelled. The tongue soon becomes 
coated along its center with a white, moist, pasty coating, while 
the edges are red and glazed. The papillae of the tongue are 
raised and project through the coating, dotting the organ with 
bright red spots. Other portions of the mucous membrane are 
apt to be involved, so that coryza or mucus purging may be 
present. Under such circumstances it is often thought that the 
child has taken cold, and a mistaken diagnosis may lead to 
medication of the air passages. After a variable time, normal 
digestion may return, sometimes rapidly, but more often slowly. 
Repeated attacks speedily influence the general health, which 
again reacts upon the stomach and favors an early recurrence of 
the trouble. There is sometimes considerable elevation of 
temperature in these cases, but often in mild attacks there is no 
perceptible pyrexia. Tenderness over the epigastrium is not a 
constant symptom, nor is it ever extreme. Pain is felt in the 
region of the stomach if the disease is acute, especially after 
eating ; but often the pain is so slight as to be hardly notice- 
able. The breath is foul and the flow of saliva may be much 
increased. Herpetic blisters (hydroa) are apt to appear about 
the mouth, especially if the systemic disturbance is great. 
Nervous symptoms are very common, sometimes of a con- 
vulsive character, and at others a disturbance of the mental 
state is noticeable. Cases of aphasia have been observed by 
Henoch and others from this cause. Very young children 
may have spasms that are either tonic or clonic, or both 
states may be present. 



168 THE DISEASES OF CHILDREN. 

There may be a disturbance of the respiratory function amount- 
ing in some to croup of the spasmodic variety, and in others to 
dyspeptic or gastric asthma. 

The diagnosis of acute gastritis is much easier that when it 
presents itself in a chronic form. In the former case vomiting, 
rapid emaciation and epigastric pain are the chief points to be 
considered, while in the latter our diagnosis is often obscured 
by the ill-defined character of the symptoms, and also by the 
presence of symptoms having but a remote relation to the 
stomach. 

Where persistent vomiting is present, however, and steady 
emaciation progresses out of proportion to the gravity of co-ex- 
isting symptoms, gastritis is doubtless present, whether there 
be pain in, or tenderness over, the stomach or not. 

In uncomplicated cases the bowels are apt to be constipated, 
but there is nearly always a diarrhea from the presence of 
entro-colitis. 

Prognosis. — Unless the inflammation is so severe or so pro- 
tracted as to disintegrate the mucous membrane of the stomach, 
there is no reason why it may not yield to judicious treatment 
and subside before the life of the infant is compromised. When 
the inflammation is associated with severe thrush, the chances 
are unfavorable, and the same is true with entero-colitis. When 
death ensues, it is generally from exhaustion. 

Tj'catment. — The first thing to be done in cases of gastritis is 
to ascertain the cause of the inflammation, for so long as the 
cause is operative, the inflammation will continue. If this be 
in the mother's milk, the infant should be weaned at once, or 
a suitable wet-nurse substituted. 

If bottle-fed, the habitual food should be changed to that 
which is more bland and unirritating. Barley water, rice 
water, or arrowroot should be given in place of foods less easily 
digested. Cream should be substituted for milk temporarily, 
and in cases of great prostration, when all food is rejected from 
the stomach, nutritive enemata may be used to great advan- 
tage. Murdock's food is admirably adapted for this purpose, 
and a child can be nourished by it per rectum for a consider- 
able time. In some cases it is absolutely useless to attempt to 
use the stomach for alimenation until the inflammation sub- 
sides. Not long since we saw a case of this kind in consulta- 
tion with our friend, Dr. S. P. Hedges. The patient was an 
infant about a year old. At the time of my first visit the 
stomach would retain nothing — not even water. Champagne in 
a few-drops doses, was instantly ejected ; koumiss had been 
tried without avail. The infant was desperately thirsty and 
clutched a cup of water with the greatest avidity. Under 



GASTRITIS— REMEDIES. 169 

these circumstances, even medication by the stomach was out 
of the question. The attack was an acute one and the child 
had been previously in good health. It was, therefore, well 
nourished and it was decided to give the stomach perfect rest 
for a day or two. Nutritive enemata were given at intervals 
and in the course of a couple of days the stomach had so far 
recovered that barley water was retained and digested. A 
week later the gastritis had entirely disappeared and did not 
recur. Since there is an excess of acid in all mucous inflam- 
mations, lime water or bicarb, of soda should be mixed with 
the milk, if the latter is tolerated. Cloths wrung out of hot 
water and placed over the stomach are very helpful, or a poul- 
tice of ground flaxseed applied hot and covered with oil silk. 

REMEDIES. 

Aconite. — In the beginning of an attack. 

Bryonia. — Abdomen distended with gas and tender to the 
touch, violent thirst, cold hands and feet. 

Belladonna. — Pupils dilated; stupor; empty retching; symp- 
toms indicating encephalic fever; jerking and twitching of 
muscles. Hartmann says that bryonia and belladonna are par- 
ticularly suitable if the symptoms of gastritis develop them- 
selves shortly after the child is weaned. 

Ipecacuanha. — Vomiting and retching continually, with other 
characteristic symptoms. 

Calcarea Carb. — The intestinal canal seems to be more 
affected than the stomach ; tendency to diarrhea more marked 
than the urging to vomit ; passages smell sour and have the 
color of clay ; great restlessness and debility ; especially indi- 
cated if the child is teething. 

Kreasotuin. — This remedy is highly recommended by Jahr^ 
who, however, does not give the special indications for its use. 
He says: "Before I became acquainted with the splendid 
virtues of kreasotum I had already lost three cases of gastritis, 
whom I had treated with calcarea and arsenicum. Since I 
have used kreasotum I have not met with a single loss." 

Tartar Emetic. — Frequent sour vomiting; empty retching 
and straining to vomit, with ineffectual urgingtodiarrheaic stool, 
or with slimy diarrhea; drowsiness with contracted pupils, quiet 
breathing and very bad humor; the child cannot be touched 
without causing it to cry. "The drowsiness and contracted 
pupils are characteristic indications for tartar emetic, whereas 
a condition bordering on soper speaks more in favor of bella- 
donna." 

Arsefiicuvt, Veratriun Alb. and PhospJioric Acid, are all 



170 THE DISEASES OF CHILDREN. 

spoken of favorably by those who have a right to speak 
authoratively on the subject. 

Argentum Nitras. — This remedy, although the last on the 
list, is by no means considered the least valuable by those who 
have used it. It is more clearly homeopathic to a pure 
gastritis than any drug hitherto mentioned. The indications 
for its employment are: excessive flatulence, the stomach 
seems ready to burst, copious eructations, which are accom- 
plished only after persistent effort, and are very violent. The 
patient is in a condition of apathy. 

If the child is old enough to describe his symptoms, he com- 
plains of great burning in the stomach. This last symptom is 
very characteristic. 

Dr. William Pepper, in the *' Cyclopedia of Diseases of Chil- 
dren," vol. III., page i6, thus speaks of this drug : " There is no 
remedy which can be given, even to the youngest infant, with 
more confidence than nitrate of silver in those cases where the 
gastric irritability is excessive, so that vomiting is a chronic 
condition. Indeed, in all the catarrhal affections of the gastro- 
intestinal mucous membrane in children, this remedy possesses 
remarkable value, although it requires great tact to determine 
the dose and the frequency, and times of administration best 
adapted to each case." 

Dr. Pepper gives a formula for its exhibition containing one- 
sixtieth of a grain (sic) at a dose, dissolved in a teaspoonful of 
water. Our 3^ trit. dissolved in water is far more effective. 



CHAPTER III. 

CONGENITAL DYSPEPSIA. 

This term is used deliberately to designate certain forms of 
indigestion attended by mal-assimilation, and yet which do not 
exhibit any of the recognizable signs of inflammation ; nor are 
they found post mortem, to have any appreciable lesion in the 
digestive canal. There is no pathological change in the mu- 
cous membrane of the stomach ; there is no rise in temperature 
to indicate pyrexia ; there is wasting, steady and persistent 
atrophy ; and yet no clue to the cause of the trouble save that 
of functional indigestion. These cases occur often in young 
infants who, soon after birth and without apparent cause, fall 
into a state of decline and fail to grow and thrive as a well- 
nourished infant ought to do, and yet whose earliest morbid 
symptoms are very different from those dependent on tuber- 
culosis, rachitis, or other of the well-marked cachexias. 

Marasmus is the term which has most commonly been used 
to describe these cases, but they are also referred to under the 
head of atrophy, inanition, wasting, and recently MM. Parrot 
and Robin have proposed a new term, atJirepsia, which, from 
its derivation, is eminently scientific and clearly descriptive ; 
but as this term has not as yet come into general use, I prefer 
the more familiar word *' dyspepsia " to any other, as indicating 
not only the nature of the disease, but also its cause, which is 
in all cases a fault or failure of the digestive function. In a 
given case the fault may be in the organs of assimilation ; in 
another, in an insufficiency or inefficiency of the liver; and 
again, the trouble, so far as we can tell, is due solely to a lack 
of innervation, in which case the stomach is wanting in nerv- 
ous tone, in stamina, in digestive power. In any case there is 
the prime condition of indigestion or dyspepsia, and as a result 
thereof we have mal-nutrition. 

Most of these babies of which I speak, are plump and w^ell- 
nourished enough at birth, and it is only after weeks, or months 
in some cases, before any serious impairment of nutrition be- 
comes noticeable, athough, in most cases, this is manifest at an 
earlier period, and in all cases, the proximity to birth, when 
more or less failure becomes apparent, warrants the presump- 
tion that the cause of the trouble is ante- rather than post- 

(171) 



172 THE DISEASES OF CHILDREN. 

natal, and that the designation of congenital dyspepsia is not 
inappropriate. 

That some, if not many, of these cases are not only congenital, 
but involve also the question of heredity, will be apparent from 
cases to be cited hereafter. 

I am fully aware of the fact that some defect in the milk of 
the mother or nurse, is a prolific source of trouble in the early 
period of infancy; and a badly-selected food in bottle-fed chil- 
dren may quickly disorder the stomach ; but the infants here 
referred to are inclined to waste and decline, and grow thinner 
and thinner on the best of food ; and indeed the better the food, 
the more they fail to thrive. 

With some babies, the slightest indiscretion in the mother's 
diet gives rise to complaint, while with other children the same 
mother may eat fruit and vegetables, and enjoy the widest lati- 
tude in eating with impunity. 

These cases of congenital dyspepsia may be readily differen- 
tiated from the acute and accidental disorders of the alimen- 
tary canal, such as gastritis, enteritis, entero-colitis, etc., not 
only by the generally well-marked peculiarities of these latter 
affections, but by the added fact that with them we have a 
period of health, and growth, and thrift, preceding the invasion 
of disease or decline, and usually, especially in serious forms of 
these diseases, we have more or less fever with its attendant 
and unmistakable symptoms. 

In congenital dyspepsia, we have a steady and progressive^ 
but slow emaciation ; an unsatisfied craving for food which en- 
genders restlessness, wakefulness, and distressful crying; but 
there is an absence of pyrexia, excepting, perhaps, occasional 
and slight febrile movements of an irritative character, which 
are transient in duration. 

The importance of recognizing these cases, and distinguish- 
ing them from other cachexias arises from the fact that if there 
be only functional impairment, as is usually the case, the prog- 
nosis is much more favorable than it can be, if a more profound 
morbid tendency be present, involving constitutional taint ; and 
the medicinal and hygienic management of these cases must 
be very different from what they would be of necessity under 
the latter circumstances. 

Two illustrative cases will serve to indicate what is here 
meant by congenital dyspepsia : 

Case I. — Baby E., female, born December 5, 1880, at full 
term ; weighed eight to nine pounds ; slept most of the time 
during the first few days ; its passages were normal and regu- 
lar, and indeed the baby seemed perfectly healthy in all re- 
spects. For a week or more all went well, excepting that 



CONGENITAL DTSPEPSTA. 173 

frequently after nursing there would be some vomiting, accom- 
panied by eructations of wind, and oftentimes crying as if from 
colic. After this the baby cried almost incessantly, unless car- 
ried in the arms ; and during several succeeding months, there 
was but little peace or quiet in this household. When the 
baby was about two weeks old, and as soon as it manifested 
signs that something was wrong, I examined the mother's milk 
carefully and repeatedly, and compared it with the milk of two 
other women who were confined about the same time. It was 
apparently the best of the three specimens. 

I could not believe that the milk was at fault, and urged 
continued nursing. The baby continued, however, to cry and 
pine. 

The mother had plenty of nourishment, and it was taken 
with avidity. The bowels were not especially disturbed ; vom- 
iting was only slight and occasional. After the third week I 
yielded my judgment to that of the parents, and commenced 
artificial feeding — first trying a wet-nurse without any im- 
provement. 

The history of the succeeding year, if complete, would fill a 
fair-sized volume. I tried nearly all available aliments from 
cow's milk, fresh and condensed, on through nearly the entire 
list of foods. When eight months old the baby's condition 
was indeed pitiable. She was but little larger than when born. 
The skin of the legs, arms and body could be raised in folds ; 
that of the face was wrinkled and old-looking — in short, I had 
a typical case of marasmus, with all that the name implies. 
About this time, cerebral symptoms set in ; such as starting in 
sleep, with a sharp, shrill cry — the '' cri encephalique " — boring 
of the head into the pillow; pupils of eyes sometimes dilated, 
and again contracted ; a whining, distressful cry was almost 
continuous, unless kept in motion. Thrush showed itself in the 
mouth ; and extensive erythema about the arms occurred at a 
somewhat earlier period, and both were more or less obstinate. 
At a later period a dropsical condition, which was more or less 
general, was manifested. Edema of the lower extremities 
was especially marked, and serous tumors would form on the 
head, sometimes closely simulating a hydrocephaloid condi- 
tion. All of these intercurrent symptoms yielded more or less 
readily to the indicated and usual remedies, leaving the maras- 
matic condition, however, but little improved. Finally, how- 
ever, after exhausting my resources, and in sheer desperation, I 
prepared a mixture of gelatine and arrowroot, according to the 
formula of Meigs and Pepper. Even this did not answer until 
all cream was substituted for milk and cream, as by them 
directed. In this case there was a complete and continuous 



174 THE DISEASES OF CHILDREN. 

inability to digest casein, and a similar inability is met with 
not infrequently. 

In the conduct of the case, injections of Valentine's meat- 
juice were used, as well as daily inunctions of olive oil. But 
with all my efforts to support nutrition, and in spite of all ex- 
pedients which were well-nigh exhaustive, it was not until the 
above preparation of gelatine and arrowroot was used that I 
could see perceptible improvement. From its exhibition the 
baby commenced to gain, very slowly but surely, and has con- 
tinued to do so to the present time. At this writing — the baby 
being now eighteen months old — her condition is as follows: 
She has six teeth, anterior fontanel unclosed, but closing ; ap- 
petite and digestion good ; sleeps well ; is happy and playful ; 
creeps about the floor, but cannot stand ; she is small in size, 
but her appearance is natural and healthy, and her face has lost 
all trace of suffering and disease. She is slowly but steadily 
growing out of a condition, which seemed for weeks and even 
months, to be almost hopeless. 

But why should this child so soon after birth — a plump and 
hearty child when born — have drifted into such an apparently 
hopeless and pitiable condition ? 

While studying the case I elicited the following facts, which 
seemed to help answer the question, and convinced me that 
heredity had much to do with it. This was the fifth baby born 
to this family. The first one weighed thirteen pounds at birth, 
showed marked indigestion before it was a month old, and died 
at the age of seven months. 

The second weighed ten pounds at birth ; was nursed three 
weeks ; then put upon artificial food, but continued to decline, 
and died at the age of seven weeks, from purging and vomiting. 

The third and fourth children were not nursed at all, but 
Harry (the fourth) had marasmus dating from his second 
month, which lasted until he was nearly a year old. The third 
child, now eight years old, has frequent attacks of indigestion 
accompanied with epileptoid fits. Both of them are under-sized 
and cachectic. 

Mrs. E., the mother, is a remarkably strong and healthy 
woman ; says she has never had a sick day in her life. Her 
father, however, was dyspeptic, and she has three aunts who are 
confirmed dyspeptics. 

The father of the family is a Virginian by birth ; a man of 
splendid physique, standing over six feet in his stockings ; a 
man of large appetite and larger passions. He is highly edu- 
cated, being a civil engineer by profession ; has traveled the 
world over in pursuit of business or pleasure, and, being a 
thorough gourmand, has had indigestion in nearly every civil- 



CONGENITAL DYSPEPSIA. 175 

ized country on the globe. He has no other defect of organi- 
zation that I have been able to discover, and hence the question 
recurs, why have these parents, who in a general way are so 
exceptionally strong and vigorous, had such a succession of 
puny and delicate children ? I cannot help the conclusion 
that the abused and deranged stomach of the father has been 
transmitted to the children, reproducing in them a dyspeptic 
condition, according to the well-recognized laws of heredity. 

Case 2. — Mrs. L., 35 years old ; weight no lbs ; height 5 feet 
6 inches; married 13 years; has had six children with easy 
labor. Last child born August 6, 1881. Baby was plump and 
weighed eight pounds when two weeks old. From birth had 
colic; constipation, alternating with diarrhea; eructations of 
wind ; vomiting of curdy masses ; stools natural enough in 
color ; fetid diarrhea for three days before death, which oc- 
curred at end of eighth week. The baby did not grow and 
increase in weight, but was not especially emaciated. Four 
of the other children died in the same manner at about the 
same age, none of them living beyond the third month, although 
all were plump and well-nourished at birth. The fourth child 
in the order of birth and the one living, now eight years old, 
has a very delicate stomach, and was only raised thus far 
by dint of care. She was wet-nursed for a time, as was the 
third child, which died at the age of six weeks. 

This woman's mother was always a dyspeptic, and died in 
middle life of gradual decline. She herself has had chronic 
diarrhea most of the time since she can remember, in spite of 
which she neither looks nor acts like an invalid. By carefully 
regulating her diet, which experience has taught her to do, she 
maintains an average amount of vigor. While having a some- 
what delicate look, she has good color, skin clear, lips red. 
Being a lady of rare culture and somewhat reduced in circum- 
stances, she has been obliged to do more or less labor of a kind 
that has taxed her mind and nervous system, and she thinks 
her babies have died from participating in her ''nervous ex- 
haustion." That this is not so, is evidenced from the fact that 
so long as her children share her blood and are nourished by 
her direct, they are well and strong, and are born red and 
plump. But as soon as they are thrown on their own re- 
sources, in the matter of digestion, they fail to thrive, and 
speedily perish. None of them ever had convulsions. The 
father of this family claims to have good digestion. He is, 
however, thin, scrawny and undersized. Morbus coxalgia in 
early life left one leg shorter than the other. 

In both the cases here cited, the presumption of an inherited 
defect of the nutritive function is certainly probable and war- 



176 THE DISEASES OF CHILDREN. 

ranted by logic and analogy. That function, as well as organi- 
zation, may be and is inherited is evidenced by volumes of 
authenticated facts. 

I know well a family of ten grown persons, all of whom have 
children of their own. In three generations there is not a poor 
or weak stomach, nor is indigestion known among them. Every 
member of the family from grandparents to grandchildren are 
hearty, ruddy and strong, and all are good feeders ; but every 
grown member of this family has defective vision, and some of 
them have worn glasses from puberty. 

Zimmerman cites the case of a whole family upon whom 
coffee acted as opium acts on others, while opium had no 
sensible effect whatever. Sir Henry Holland says that he 
knows of a family where four out of five children, otherwise 
healthy, became totally blind from amaurosis about the age 
of twelve, the vision having been gradually impaired up to this 
time. 

Indeed, the evidence is ample to show that we inherit from 
our parents, not alone the general form and features, the bony, 
muscular, nervous and glandular structures, but the foibles, the 
weaknesses, susceptibilities and morbid tendencies as well. 
But I do not propose to discuss here the general question of 
disease transmission, nor insist upon it that all cases of defect- 
ive nutrition in the infant are inherited; but I do maintain 
that many, if not most of them, date from birth, and are hence 
congenital. 

The practical and all-important deduction from these prem- 
ises is that the physician who has to treat these babies must be 
quick to realize the situation, and treat them accordingly. No 
Procrustean bed will answer for these cases. It will not do 
here to force unassimilable food. Their weak and delicate 
stomachs are utterly unable to appropriate and absorb that 
which is generally regarded as wholesome and nutritive. What 
is cibus deoriim to a healthy babe is stercus diaboli to such 
children as these. 

And yet these cases are by no means hopeless. On the con- 
trary, a careful and intelligent selection of food, a judicious but 
persistent hygiene, and the homeopathic treatment of the 
symptoms as they arise, will surprise the most sanguine and 
excite the wonder of those who are disposed to be skeptical. 

Diagnosis. — A word or two upon the diagnosis and treatment 
of these cases. But little need be said under either heading, 
but that little may be important to the junior members of the 
profession. 

The only one of the constitutional diseases which is likely to 
be mistaken for congenital dyspepsia is tabes mesenterica ; but 



CONGENITAL DYSPEPSIA. 



Vil 



there are certain distinctive differences which will be 
apparent, by a comparison of the two affections. 



very 



TABES MESEXTERICA. 

Mesenteric glands always hypertro- 

phied. 
Appetite voracious. 
Stools liquid, ptitrid and corroding. 

Fever intense and continuous. 
Greedy thirst. 

Tympanitis always and continuous. 
Commences during dentition. 
Atrophy of brain, with distortion of 

calvaria. 
Great debility and prostration. 
Dropsy early in the disease. 
Fatal tendency. 
Emaciation rapid. 



CONGENITAL DYSPEPSIA. 

Mesenteric glands not hypertro- 
phied. 

Appetite variable. 

Stools thin and frequent but not pu- 
trid. 

No continued fever. 

Little or no thirst. 

Tympanitis occasional and transient. 

Prior to dentition. 

Head preserves its normal contour. 

Strength well maintained. 
Dropsy late. 
Prognosis hopeful. 
Emaciation slow and gradual. 



Histological. — As to the morbid anatomy of this affection, 
little is definitely known. Those that die generally perish 
from some intercurrent complication which was not neces- 
sarily part of the original trouble. 

Primarily there is only one morbid condition : a functional 
deficiency, a lack of digestive power. The peptic glands may 
be sufficiently matured, but they are inactive. The liver may 
be relatively proportionate, so far as size and bulk are con- 
cerned, to the general weight, but it is sluggish and inefficient. 
In consequence the stools are white or grayish and papescent. 

That a congenital feebleness of the digestive function, such 
as is here indicated, may exist even to a fatal extent, is shown 
by some experiments of Claude Bernard on the lower animals. 
He says, " Experience has taught us that patients often die 
without offering in the post-7nortein examination the slightest 
modification in the anatomical condition of their organs. In 
the course of our physiological experiments, we often see dogs 
arrive at the very last stage of emaciation, although the 
appetite continues unimpaired till the last moment. They sink 
from sheer exhaustion, while the lacteals are gorged with 
chyle; and, when opened, their bodies ofTer no trace whatever 
of pathological alteration."^ 

Treatment. — I need scarcely say, there is no specific for this 
affection. Each case will show peculiarities which will require 
a careful study of remedies and render a selection oftentimes 
difficult. The symptoms alone will furnish a safe guide. At 
certain stages the remedies will have to be changed frequently 



* Lecture on 
Gazette, i860, vol 



Experimental Physiology, by Claude M. 
I, page 209. 

D.C.— 12 



Bernard, Med. Times and 



178 THE DISEASES OF CHILDREN, 

to meet new and sometimes unexpected complications. The 
treatment must always, of necessity, be largely dietetic and 
hygienic, and the aliment must be selected with reference to 
the capacity of the given case. In these cases rules which 
should govern healthy children, must be ignored, or at least 
held in abeyance. In the selection of food, it will often be 
found that a most unpromising food for a well-bred stomach 
will be just the thing here, e. g., gelatine and arrowroot, as in 
the case before cited. 

One thing must not be forgotten. These children cannot 
digest casein without artificial help. Theoretically, the 
addition of a small quantity of Hale's comp. digest, or lacto- 
peptine, ought to aid its digestibility. By the addition of 
pepsin in some form the nitrogenous element of the milk 
ought to be sufficiently peptonized before taken into the 
stomach to render the milk perfectly assimilable. Practically, 
my experience has been so limited with these *'aids," that I 
cannot speak authoritatively. Cream, either clear or mixed 
with Mellin's food and made very dilute, has usually served 
me well, and has proven in several cases the only food for the 
incipient stage. Cod-liver oil, in emulsion or otherwise, will 
often prove serviceable. Inunctions of olive oil, cod-liver oil 
or the more elegant preparation known as the " unguentum 
graecorum," which is made of cocoa-butter and almond oil, is 
of decided advantage and should be used daily. The oil bath 
should be substituted for the water bath, the latter being 
used as sparingly as possible. 

The value of fresh air is inestimable, and should never be 
forgotten. Warmth is a sine qua non of cure, and it is almost 
impossible to keep these children too warm. Their blood 
easily chills, and they require to be kept in a warmer room, and 
to be more warmly clad than their more robust brothers and 
sisters. 



CHAPTER IV. 

DIARRHEA. 

Definition and Characteristics. — Diarrhea is one of the most 
frequent of all the ailments of infancy and childhood. By the 
term is meant, an unusual frequency of the alvine discharges 
with more or less change in their peculiar characteristics. The 
normal frequency of stools in a healthy infant during its first 
month should be from three to four in the twenty-four hours. 
After this period and during the first year, the daily average of 
stools should be at least two and in a hearty child may be 
double this number without any cause for apprehension, pro- 
vided the character of the stool is normal and the system does 
not suffer in consequence. 

Immediately after birth the discharges from the bowels are 
dark-green or brown or even black in color, due to the meco- 
nium. During the early period of infancy, the discharges are of 
a soft, papescent character, light yellow in color, and devoid of 
fetor. During the remainder of infancy, they are still soft, more 
frequent than in adult life and yellow or of light-brownish hue. 
Normal stools in infancy are homogeneous in character, what- 
ever the consistency or color. 

Light gray or clay-colored stools denote an absence of bile 
and may indicate hepatic disease. 

In chronic diarrhea, the stools are thin, dark-brown and intol- 
erably fetid. Meat juice, especially the meat extracts, give 
to the stools a dark color and great fetor. 

The dark-green color of the stools is due to bile, which is 
turned green by the acid character of the intestinal secretions. 

Where bright blood is passed in the stools it comes from the 
colon ; blood from the ileum is turned brown before being dis- 
charged. 

Frothy acid discharges from the bowels, of a light yellow or 
slightly green color, indicate a disturbance of the digestive 
functions ; generally from overfeeding or improper food. 

Discharges of slimy mucus occur in irritations of the bowels, 
from worms or teething ; or they are the consequence of an 
increase of the mucus exhalation of the follicles of the intes- 
tines, caused by the impression of cold upon the surface. 

Repeated discharges of viscid mucus, occasionally streaked 

(179) 



180 THE DISEASES OF CHILDREN. 

with blood, or of a greenish fluid, mixed with small masses 
resembling the curd of milk, are frequent in most of the inflam- 
matory affections of the bowels. 

A deep-green color of the stools, the discharges resembling 
chopped grass or spinach, is generally a symptom of serious 
disease of the stomach or intestines ; and is a striking feature 
of acute gastritis, and the more acute grades of gastro-intestinal 
inflammations. 

A diminution in the number of stools, when diarrhea occurs 
as a symptom of disease in children, with a return to the ordi- 
nary healthy condition in the color and consistence of the dis- 
charges, is a favorable symptom. So, also, is the appearance of 
natural feces in cases of dysentery, and of bile in the discharges 
in cholera infantum. 

The passage from the bowels of the substances taken as food 
entirely unchanged, or but little altered, constitutes a condition 
called lienteria, and indicates excessive irritability of the ali- 
mentary canal. It occurs in inflammation of the stomach and 
bowels, but more frequently in protracted cases of cholera in- 
fantum and chronic diarrhea. 

Diarrhea in children does not always indicate disease, nor 
does it always call for medicinal treatment. When irritating 
substances have been taken into the stomach, which are not 
nutritious and cannot be made useful in the economy, nature 
seeks to rid herself of the foreign substance, either by vomiting 
or a salutary diarrhea. In either case, it would be folly to in- 
terfere with the process, since no possible good could be ac- 
complished by so doing. But it often happens that the diar- 
rhea, which was salutary in the beginning, continues even after 
the end is accomplished from the irritation thus set up, and 
needs to be controlled before serious, or at least, unnecessary 
loss of strength is occasioned. 

Some writers divide this subject of diarrhea into a great 
number of varieties, basing the division upon the location of 
the pathological lesion, or its supposed location, and again 
multiplying terms according to the real or fancied condition 
causing the diarrhea. These pathological names are in our judg- 
ment a hindrance rather than a benefit, since nothing short of a 
post-mortem investigation can determine in a given case, whether 
the exact seat of the lesion is in the upper, lower, or middle third 
of the ileum, or an inch beyond its junction with the colon. The 
division of diarrheas into bilious, mucous and serous has a bet- 
ter recommendation ; but this is more theoretical than practi- 
cal, since the discharges rarely maintain for a length of time 
the characteristics with which they began. In order to avoid 
prolixity and retain sufficient accuracy of description for all 



SIMPLE DIARRHEA. 181 

practical purposes, we shall consider all forms of diarrhea under 
the following heads, viz.: Simple, or non-inflammatory diarrhea ; 
entero-colitis, or inflammatory diarrhea ; cholerine, or cholera 
infantum, and hemorrhagic diarrhea, or dysentery. 

Simple X^ik'^'^w?.^— Definition. — This is the most fre- 
quent form of diarrhea encountered in infancy and childhood. 
It is non-inflammatory in character, but if its producing cause 
be not arrested, it may lead to a catarrh of the bowels or to 
inflammation (entero-colitis). Its duration is variable. It may 
last but a few hours, and then cease spontaneously, or the 
evacuations may occur every few minutes and continue with 
little or no abatement for a considerable length of time, ex- 
hausting the strength of the patient and producing extreme 
emaciation. 

Causes. — The causes which may give rise to this form of 
diarrhea are innumerable. Anything which disturbs the func- 
tion of alimentation, in the way of food which is not assimila- 
ble, or which disorders the nervous system so as to lower the 
tone of the digestive apparatus ; anything which checks the 
cutaneous transpiration and thus congests the mucous mem- 
brane ; anything which disturbs the equilibrium of the circula- 
tion ; any or all of these influences may give rise to simple 
diarrhea. Probably the most prolific causes are acrid or irritat- 
ing food, and the influence of cold. The use of farinaceous food 
at too early an age, when the digestive powers of the infant are 
unequal to the task of effecting the necessary changes in it to 
render it assimilable, has already been spoken of and its dan- 
gers pointed out. Other articles of food are perhaps equally 
injurious. The unhealthy state of the nurse's milk is another 
cause of frequent occurrence. The indiscriminate diet allowed 
after an infant is weaned is a fruitful source of gastric and in- 
testinal complaints. So also is the effect of cold and wet ap- 
plied to the surface of the body, and still more, the sudden 
transition from a heated to a chilly atmosphere. The effect is 
to constringe the skin, and direct the course of the blood to 
the internal surfaces, where it first produces engorgement of 
the vessels and then a relaxation of them. Insufficient cloth- 
ing, especially in our changeable northern climate, is responsi- 
ble for many a diarrhea of more or less serious character. 
Infants who are carelessly allowed to become uncovered at 
night after the fires have gone down are very liable to bowel 
complaint. Extreme heat, if much prolonged, is a well- 
known cause of diarrhea. Its effect is to relax the system 
and produce an enervated condition at variance with the 
demands of complete digestion. Certain foods, too, are espe- 



182 THE DISEASES OF CHILDREN. 

cially liable to fermentative changes in hot weather, and if 
taken into the stomach quickly produce disorder there or 
in the intestinal tract below. The influence of dentition in 
this connection will be treated subsequently under its appro- 
priate head. 

Histological. — Simple diarrhea is a purely functional phe- 
nomenon, and therefore is not accompanied by any structural 
or anatomical change, unless tumefacation of intestinal follicles 
may be so regarded. There may be in these cases some dimin- 
ished firmness of the mucous membrane, and more or less 
swelling of the glands of Peyer, but no lesions characteristic of 
inflammation. Niem.eyer — and others also — describe all forms 
of diarrhea, even the mildest, under the term " catarrhal inflam- 
mation," and consider even the transient effects of a purgative 
as an incipient catarrh. But it seems much more rational to re- 
gard those diarrheas, which immediately abate with the removal 
of the cause and which are unattended by marked anatomical 
change, as non-inflammatory. 

Symptoms. — Simple diarrhea may come on suddenly and with- 
out precursory symptoms or indications of gastric uneasiness, 
or symptoms of indigestion may precede for a day or two. 
When these prodromic symptoms are present they are ill defined 
and are mainly restlessness, disturbed sleep, transient abdom- 
inal pains, loss of appetite and perhaps nausea or vomiting. 
The stools vary greatly, both in color and character. In young 
infants they are apt to be green, even when the cause is most 
trivial. If the diarrhea occurs in a nursing infant or one who 
is bottle-fed, particles of coagulated casein are apt to be scat- 
tered through the stool. If the stools are acid in their reaction 
or to any extent irritating, there may be more or less tenesmus. 
The frequency of stools diminishes during the night, for the 
reason that food and drink are then suspended. In mild attacks 
there is but little thirst, but if the stools are frequent and 
copious, the thirst may be great. The tongue is moist. There 
may be some meteorism, but no abdominal tenderness. The 
loss of weight and firmness of flesh which may follow or result 
from a simple diarrhea in a brief space of time is amazing. A 
few days may suffice to lose the rotundity of limbs and render 
the tissues soft and flabby. The great danger in simple, non- 
inflammatory diarrhea arises from the fact that it may speedily 
and imperceptibly take on an inflammatory form, or if the 
season be favorable, that more serious one still — cholera infan- 
tum. In mild cases the stools do not altogether lose their 
feculent character, but are more frequent, copious and thinner, 
and the odor becomes pungent and offensive. 

Prognosis, — So long as the diarrhea remains simple the prog- 



IN FLA MM A TOR V DIA RRHEA . 1 83 

nosis is favorable, even though the emaciation be considerable 
and the disease prolonged. During the heat of summer there 
is more danger than when the weather is cool, and always more 
danger in city than in country. 

The greatest danger arising from simple diarrhea, is from 
exhaustion. The drain upon the fluids of the body and the 
consequent exhaustion may produce such a condition of debil- 
ity as to affect the brain and cause spurious hydrocephalus. 
The physician should always be on his guard in severe cases of 
diarrhea lest the exhaustion resulting therefrom be more pro- 
found than he is aware of. The cessation of the discharges is 
not always a good omen. It may be due to such a state of 
enervation that the secretory function of the intestines is sus- 
pended, or to a failure of the peristaltic movements of the 
bowels. We can never be sure that all danger is past, until 
amendment has been maintained for a day, and normal stools 
have appeared. 

Treatment. — In order to avoid needless repetition we shall 
treat all the forms of diarrhea together at the close of the 
chapter. 

Inflammatory Diarrhea.— (Entero-colitis ; Febrile Diar- 
rhea ; Intestinal Catarrh.) 

Defi7tition. — Under this head we propose to treat of that 
form of diarrhea which is attended with fever and other 
symptoms of intestinal inflammation, whether it be situ- 
ated in the ileum, the colon, or, as is commonly the case, 
in both. 

We have already referred to the difficulty of locating with 
any exactitude the precise seat of the intestinal lesion in these 
cases, and writers generally are free to admit that there is no 
special difference in the symptoms by which one can tell, in a 
given case, whether the inflammation is in the small or the large 
bowel. Billard, who is conceded to be one of the closest of 
observers, after analyzing eighty cases of intestinal inflamma- 
tion in infants, says: ** In consequence of the impossibility we 
have found to exist of tracing with exactitude the series of 
symptoms proper to inflammation of the different portions of 
the digestive tube, we shall content ourselves with presenting 
an analytical sketch of the causes, symptoms, and ordinary 
course of inflammation of the mucous membrane of the intes- 
tines in general." 

In using either of the above terms, therefore, we shall intend 
to refer to an inflammatory condition of the bowels, without 
special reference to its exact locality, or whether the inflam- 
matory process be extensive or limited. 



184 



THE DISEASES OF CHILDREN. 



COMPARATIVE MORTALITY OF DIARRHEAL DISEASES BY QUAR- 
TERS FOR EIGHT YEARS, FROM 1 885 TO 1 892 INCLUSIVE. 



Quarters. 


1885. 


1886. 


18S7. 


188S. 


18S9. 


1890. 


1891. 


1S92. 


Total 

for 
Quar- 
ters. 


Spring 

Summer 

Autumn 

Winter 


187 

861 

65 

35 


162 

841 

88 

43 


1036 
79 


129 

1018 

71 

38 


88 
1350 

29 


177 

1284 

105 

^51 


350 

1286 
218 
141 


262 

1347 

145 

"3 


I58S 

8923 

914 

629 


Totals by yrs . 


1 148 


"34 


1419 


1256 


1618 


1717 


1995 


1867 


12054 



MORTALITY, BY MONTHS, FOR YEAR 1 892. 



Month. 



January... , 
February. . 

March 

April 

May 

June 

July 

August. . . . 
September 
October . . . 
November. 
December , 

Total. . . 



Cholera 
Lnfantum. 



26 

8 

9 

22 

25 
98 

444 
360 

155 
42 

13 
9 



Cause of Death. 



Dysentery. 



6 

5 

2 

4 
2 
8 
II 
6 

4 
2 



54 



Entero- 
colitis. 



13 

9 
6 
21 
17 
34 
62 

84 
46 

13 
10 
II 



326 



Simple 
Diarrhea. 



19 

5 
3 
11 
10 
9 
47 
49 
35 
21 

9 

5 



223 



Etiology, — It seems unnecessary to repeat again what has 
been said in a previous section regarding the causative influences 
that are a constant menace to the lives of infants and children, 
especially those who live in our large cities. What is there 
said of the causes of simple diarrhea is equally true of that 
inflammatory form which we are now considering. There are 
some lessons to be drawn, however, from the foregoing tables 
of statistics which ought to be impressed upon the reader. The 
great mortality from diarrheal diseases during the months of 
June, July and August would naturally lead one to infer that 



INFLAMMA TOR T D lA RRHEA . 185 

the heat of summer was the principal, if not the only factor in- 
volved, and that the greater the elevation of temperature in a 
given year, the greater the consequent mortality. This is only 
partially true. If it were wholly so, we should expect to find 
the relative mortality just as great in proportion in the smaller 
towns and in the open country as in the wards of a great city. 
But this is not borne out by the facts. 

Entero-colitis is by no means as prevalent proportionally to 
population in the former as in the latter. Indeed, it is com- 
paratively rare for a child to die of summer complaint in the 
country, although the difference in temperature between it and 
the city may be but little. There is manifestly another factor 
which has a greater influence than mere heat, and this factor is 
a sanitary one. 

In the large cities the population is overcrowded, and the 
poorer classes live in cellars that are damp, and alleys that are reek- 
ing with filth. Besides this, the food supply is stale and al- 
ready undergoing incipient decomposition before it reaches the 
consumer; and here we have the real cause of the terrible mor- 
tality that gives the urban infant less than one chance in two to 
see its fifth birthday. In Paris, where the streets are kept clean 
both summer and winter, and where overcrowding is forbidden 
by law, where all food is inspected before it is distributed, there 
is no such mortality as we have in this country and England. 
A lady once told me that she was going to Paris soon where 
her parents resided, in order that her babe might escape the 
perils of its second summer. "Because, you know," she said, 
** in Paris babies do not have any * second summer.' " In the 
Foundlings' Home in this city nearly every bottle-fed infant dies 
before the summer is over. But such facts as these are too 
well known to require discussion. In this city, every summer, 
as soon as the warm weather begins, through the munificent 
bounty of my friend, Mr. Victor F. Lawson, proprietor of the 
Chicago Daily News, a sanitarium is opened on the lake shore, 
opposite Lincoln Park, where infants and children are brought 
from all over the city, and permitted to remain there through- 
out the day, enjoying the lake breezes from morning till night, 
as well as a ride on the open water on steamers that transport 
them back and forth. While at the sanitarium they are sup- 
plied with fresh milk and other foods, the best the market af- 
fords. In this way the lives of scores, if not hundreds, of chil- 
dren are saved every summer. I have repeatedly seen the good 
effects, in my private practice, of sending infants, affected with 
diarrhea, on the water for a daily trip. The value of fresh air 
and the cool, uncontaminated atmosphere of the lake is quickly 
apparent. 



186 THE DISEASES OF CHILDREN. 

The great difficulty, which almost amounts to an impossibil- 
ity, of obtaining cow's milk in the city before it has undergone 
more or less decomposition, has induced me of late years to 
advise mothers to use only condensed milk during the summer 
months. I have seen a material abatement of bowel troubles 
since I have done so. 

But no preparation of milk or other food compares, for very 
young infants, with breast milk, and this should always be 
secured, if possible, for those under nine or ten months of age. 

Symptoms. — The inflammatory diarrhea of infancy commonly 
commences with a slight febrile movement, with restlessness 
and languor and a diarrhea so mild as scarcely to attract atten- 
tion. The stools, while thinner than usual and somewhat 
more frequent, vary greatly in appearance, being at first 
yellow, brown or green. 

The tongue in the commencement of the attack is usually 
moist, but as the disease advances it becomes more dry and is 
covered with a light fur. Vomiting is common, especially in 
severe cases. In sub-acute cases the stools are not very 
frequent, numbering not over four or five in twenty-four 
hours; but they have a very bad odor and contain mucus and 
undigested food. The food remains depend of course on the 
■diet. If this is milk principally, white masses of fat and 
occasional particles of curd are constant. If the food consists 
of oat-meal, rice or barley, these cereals can be readily 
detected in the stools with the naked eye. If only broths, 
peptones and other pre-digested foods are given, the stools may 
consist almost entirely of intestinal secretions, mucus, bile and 
epithelium cells. The most constant feature of these stools is 
glairy mucus, stained with bile and mixed with fecal masses 
and undigested food. Fresh blood is rarely seen, except 
occasionally in the beginning of the attack, and then is due 
rather to congestion than ulceration. In severe or acute cases 
the number of stools may be as high as twenty or thirty in 
twenty-four hours ; but the larger proportion of them is usually 
small in amount, being often only a little mucus, or mucus 
streaked with blood. The frequency of the stools is greater 
during the daj^ than night. After the disease has lasted for a 
time, the moist tongue becomes dry and parched and the lips 
crack and bleed. All varieties of stomatitis are liable to be 
present in these cases, but thrush is by far the most common. 
In some cases the stools are quite uniform in appearance 
throughout the disease, but more often they are variable, no 
two of them being alike. The skin is usually dry and the 
quantity of urine is diminished. In protracted cases the acrid 
character of the stools excoriates the nates, and produces an 



IN FLA MM A TOR 2' DIA RRIIEA . 187 

erythema which may extend down and around the thighs and 
lower part of the abdomen. Boils on the forehead and scalp 
are common and troublesome. 

On account of the enfeebled circulation, hypostatic pneu- 
monia is common, affecting usually the posterior and inferior 
portions of the lobes and extending but a little way into the 
lungs. The only prominent symptom of hypostatic pneumonia 
being present, according to Dr. J. Lewis Smith, is an occasional 
cough. Limited to a small and almost immovable portion of 
the lung, it does not ordinarily accelerate respiration or render 
it painful, and the cough is also apparently painless. 

Diagnosis. — As already stated, the symptoms do not always 
indicate the precise locality in the bowels which is the seat of 
the inflammation, but post-mortem investigations show that 
in the vast majority of cases the lesion is either in the lower 
portion of the ileum or in the colon. The presence in the 
stools of glairy mucus, or of mucus tinged with blood, is 
pretty good evidence that the colon is principally involved. 
There is usually but little abdominal tenderness, and pain is 
either absent or causes but little complaint. Its presence or 
absence is no aid in diagnosis. The frequency of the stools 
and their admixture with mucus and blood ; the presence of 
fever and vomiting; the attendant prostration; the gradual 
approach of serious symptoms, and the symptoms of indiges- 
tion which generally precede the bowel trouble by several 
days, are sufficient ordinarily to enable one to make a correct 
diagnosis. 

Prognosis. — Entero-colitis is always a serious disease, but not 
by any means a necessarily fatal one. Many cases are met 
with, characterized by some gastro-intestinal symptoms, vomit- 
ing, high temperature, diarrhea, and nervous manifestations, 
which are convalescent in a few days, and make a quick and 
complete recovery. Other cases, and these are in the majority, 
drag along for an indefinite period and terminate after weeks 
or months, either fatally from exhaustion or from some compli- 
cation, or make a slow or tedious recovery, after weeks or 
months of tardy convalescence. If the inflammatory condition 
results in follicular ulceration, the chances of recovery are 
very small. The diagnosis of follicular ulcers is difficult, and 
can only be made from taking the case as a whole. *' If a deli- 
cate infant, which from time to time has been specially prone 
to diarrheal attacks, especially if it has had symptoms of a mild 
catarrh of the colon, has an attack which starts in with green 
mucus stools, and which continues with unabated severity for 
a week or ten days, with low fever, we think of acute follicular 
inflammation as certain and of ulceration as probable. If these 



188 THE DISEASES OF CHILDREN. 

symptoms continue for weeks without intermission, the child 
all the time failing steadily in strength, the probability becomes 
almost a certainty. 

'' If, on the contrary, after three or four days of acute symp- 
toms, there is improvement in the stools, and one occasionally 
quite fecal in character, and if after a few days another such 
exacerbation occurs, succeeded by another remission, and so on, 
we may be tolerably sure that no ulcers have yet formed." — 
L. Emmet Holt, M. D. 

In cases of follicular ulceration, the temperature is apt to 
run comparativel}^ low, the stomach is but little disturbed, and 
the course of the disease is slow and irregular. 

The greatest danger in these cases arises from complication. 
During the hot months there is danger from cholera infantum, 
as a sequela. At any season of the year, there is constant dan- 
ger of serous effusion taking place into the encephalon, pro- 
ducing spurious hydrocephalus. When this occurs or is 
threatened, there is soper alternating with'extreme restlessness 
and a return of vomiting. Emesis occurring at a late stage of 
infantile diarrhea is always a bad prognostic sign. 

Treatment. — The successful treatment of these cases necessi- 
tates a thorough knowledge of the producing causes, and the 
ability to improve the hygienic environment. A change of air 
from city to country is oftentimes a sine qua no7t of cure. These 
children must have plenty of fresh, pure air. If this can be had 
at home, well and good; but if not, no time should be lost in 
seeking the country. 

If the baby is but a few months old and is being hand-fed, or 
if it has just been weaned, a return to the breast, if only tem- 
porarily, may be imperative. Where this is impracticable, some 
one of the "baby foods," either domestic or commercial, will 
have to be tried. All milk should be boiled and peptonized^ 
so as to get rid of all curds. Barley-water will be found very 
useful with young infants. Raw-meat juice must not be for- 
gotten. 

As there is usually more or less thirst, fluids are eagerly 
taken, and with a little care the drink can be made nutritious 
as well as satisfying to the thirst. Toast-water and the bread 
jelly spoken of on page 56 are good. As the appetite is slight 
and precarious, a frequent change in aliment is required. Milk, 
if properly prepared and fresh, is all right, if it can be digested. 
Children over a year oM often take koumiss with avidity, and 
there is no milk preparation so easily digested. It satisfies 
thirst while affording much nutriment. 

If the measures, already prescribed, fail, we may still find a 
successful pabulum in the yolk of a hard-boiled ^gg — boiled so 



I NFL A MM A TORT DIA RRHEA . 189 

long that the yolk is mealy — or wine whey, of which the child 
may take considerable quantities without detriment. Dr. Meigs 
advises, in some cases, the white of an ^%% stirred in a small 
glass of water, which, he says, the child will usually drink with- 
out recognizing the presence of the albumen, "and we are thus 
enabled to administer a considerable amount of nutritious food, 
by giving the whites of two or three eggs in the course of the 
day." 

Great care must be taken, even during convalescence, not 
to overtax the digestive powers. 

The rule for feeding should be " little and often," rather than 
much at a time. 

Local measures are of very great value in these cases, and 
should never be neglected. The main seat of the inflammation 
is, as we have seen, more often than otherwise, in the colon 
and in the lower half of it, sometimes being confined to the sig- 
moid flexure. When this is the case, nothing but good can 
come from flushing out the bowels with hot water, containing 
some soothing alkali, such as borax. It cleanses the gut of all 
offending matter, soothes the irritation of the mucous membrane, 
and acts as an astringent to the congested circulation. When 
used for their local effect, the enemata may consist of from two 
to four ounces of water as hot as can be well borne, into which 
has been dissolved a third of a teaspoonful of powdered borax. 
This may be given once or twice daily or even oftener. Where 
the inflammation is high up in the colon, the whole viscus may 
be irrigated. This is accomplished by inserting a large-sized 
flexible catheter or rubber rectal tube and carrying it through 
and beyond the sigmoid flexure, so as to reach as near as possi- 
ble the ileo-cecal valve. In this way the whole colon can be 
flushed. At least a gallon of water is necessary, into which 
half an ounce of borax should be dissolved. Hamamelis (witch 
hazel) may be used to advantage in some cases instead of borax, 
especially when there is either fresh blood in the stools or when 
the discharges contain considerable quantities of inspissated 
mucus. The hamamelis may be used in the proportion of one 
part to eight of water. A large-barreled, hard-rubber syringe 
may be used to force the injection, or, still better, a fountain 
syringe, the bag of which should be held a few feet above the 
patient. When irrigation is used, once a day is often enough 
to repeat it. 

Moist and hot applications to the exterior of the abdomen 
are also useful. These may be applied in the form of fomenta- 
tions, i. e.y cloths wrung out of hot water and covered with 
oiled-silk or rubber cloth, or in the form of a poultice made 
with ground flaxseed stirred up with boiling water. The poul- 



190 THE DISEASES OF CHILDREN. 

tice should be spread on cheese-cloth and applied as hot as 
can be borne without discomfort. When cool it should be re- 
newed. These measures, simple as they are, are of great bene- 
fit and are indorsed by the highest authorities both of Europe 
and this country. 

Medicinal Treatment. — There is scarcely any other affection 
that requires such close discrimination as this in the selection 
of the appropriate remedies. The disease itself is inclined to be 
kaleidoscopic. Its features are subject to frequent changes, 
while the stools are of almost infinite variety. There are, 
however, associated symptoms, which, taken together — and 
they must be so taken — give one a picture of the remedy, if we 
take the trouble to go deep enough into the-ir differential sig- 
nificance. There is no specific for this affection, and rarely a 
single remedy that will cover the totality of the symptoms. 
The character of the stool is but one of the many guides to the 
selection of a drug in a given case ; every trifling element which 
goes to make up this character should be studied — the color, 
odor, form, consistency, frequency, are all of them important. 
Then the mental condition of the patient should be consid- 
ered, whether apathetic or irritable ; the general state, whether 
cachectic or otherwise. Only by a close and exhaustive scru- 
tiny, and a careful weighing of each particular symptom, is it 
possible to meet the indications and requirements of the par- 
ticular case in hand. Sometimes so trifling a symptom as the 
time of aggravation, whether morning, noon or night, furnishes 
the key to the whole case. More than once, when three or 
four different remedies seemed to be equally called for, the 
choice has been made by the help of so trifling a differential 
point as vomiting without thirst. (Antimon. crud.) 

In Simple Diarrhea the remedies most generally called 
for are as follows : 

Antimonium Crud. — Stool watery, often profuse, alternat- 
ing with constipation ; tongue coated white ; no thirst ; worse 
at night and early in the morning ; cutting pains before stool ; 
prolapsus ani ; child cannot bear to be touched or looked at. 
Violent vomiting excited by taking food or drink. 

Belladonna. — Stools thin with green mucus, bloody mucus, 
granular, yellow, slimy mucus ; watery ; worse in the after- 
noon and after sleeping; colic; tenesmus after stool ; head hot; 
easily startled ; rolling head from side to side ; delirium during 
sleep or just after stupor; lethargy with flushed face; children 
cry much and are ver>^ cross ; tongue dry and red at the tip ; 
sleeps with mouth open ; constant chewing ; aversion to food ; 
partial or general spasms, with unconsciousness ; involuntary 
urination ; abdomen distended and tender ; dry heat ; quick, 



INFLAMMA TOR T DIARRHEA. 191 

hard, small pulse; sleepiness with restlessness. Characteristics: 
drowsiness, with startings, dry heat, and frequent drinking. 

Bryonia. — Stools brown, thin, fecal, undigested, frequent, 
involuntary during sleep, smelling like rotten cheese ; worse in 
the morning in hot weather ; often suppression of exanthemata ; 
nausea after sitting up ; worse from motion ; desire to get out 
of bed ; desire for things which are refused when offered. 

CJiavioinilla. — Stools green mucus ; mixed green and white 
mucus, like chopped spinach ; slimy mucus; scalding, frequent, 
smelling like rotten eggs ; worse during dentition ; diarrhea fol- 
lowing a cold ; colic during stool ; peevishness — children cry 
much and can only be pacified by being carried about ; tongue 
and mouth dry ; moaning in sleep. Best given in recent attacks ; 
benefit of short duration. 

Colocynthis. — Stools saffron yellow ; frothy, liquid ; first 
watery and mucus, then bilious and lastly bloody, thin, greenish, 
slimy and watery ; worse after eating and during dentition ; 
cutting colic ; great urging; tongue coated white or yellow; 
much thirst ; nausea lasting until falling asleep and returning 
after waking ; severe colicky pains are characteristic. 

Croton Tig. — Stools yellow, watery, which come out like a 
shot; worse after drinking and while nursing; constant urging 
to stool ; dry parched lips ; excessive nausea. The three highly 
characteristic symptoms of croton tig. are the yellow, watery 
stools, sudden expulsion, and aggravation from eating and 
drinking. 

Nux Vomica. — Stools thin, brownish mucus ; thin, bloody 
mucus ; frequent, small ; after drastic medicines or prolonged 
drugging; violent tenesmus; tongue coated thick; pale, earthy 
color of face ; gums swollen, bleeding ; bad smell from the 
mouth ; thirst ; loss of appetite ; frequent but ineffectual efforts 
to urinate ; debility ; jaundice ; much gas in stomach and bowels. 

PodopJiyllin. — Stools watery, greenish watery ; jelly-like 
mucus, chalk-like, fecal ; profuse, frequent, gushing, painless ; 
very offensive, like carrion ; worse in the morning and at night, 
worse after eating or drinking ; prolapsus ani ; rolling of the 
head during dentition ; bad breath ; tongue dry and coated 
yellowish or white ; gagging or empty retching ; sallowness of 
skin ; jaundice characteristics. The stools are profuse and gush- 
ing, each seeming to drain the patient dry. There may be also 
violent cramps ; changeable stools with meal-like sediment. 

Sulphur. — Stools watery, frothy, fetid, slimy, excoriating, 
involuntary ; worse in early morning, after taking milk, after 
suppressed eruptions, during dentition ; open fontanels ; sleep- 
ing with eyes half open ; wakefulness. The early morning 
exacerbation is very characteristic. 



192 THE DISEASES OF CHILDREN. 

EnterO-COLITIS — Aconite. — Stools watery, bloody, slimy 
mucus, small, frequent; tenesmus; restlessness; won't be 
covered up ; lips dry and parched ; unquenchable thirst ; 
nausea, vomiting ; violent pains in abdomen ; full, hard, very 
quick pulse ; dry, hot skin. Only useful in beginning of acute 
cases. 

Arsenicum. — Stools thick, dark-green mucus, frequent, 
scanty, corrosive, offensive, worse at night and after eating or 
drinking ; worse after midnight ; great restlessness, constantly 
changing place ; violent, unappeasable thirst ; vomiting after 
eating or drinking; dry heat ; great prostration ; rapid exhaus- 
tion ; emaciation ; very rapid and weak pulse ; diarrhea generally 
painless. The two characteristics of ars. are thirst and rest- 
lessness. 

Ipecac. — Stools green mucus, grass-green, bloody, fermented ; 
worse at night and during dentition ; face pale ; no thirst ; 
great nausea ; flatulent colic ; spasms ; sleeps with eyes half 
open. Continuous nausea is the most characteristic symptom 
of ipecac. 

Iris. Vers. — Stools watery, greenish, undigested ; tenesmus ; 
vomiting of ingesta and of bile ; vomiting of sour fluid ; vomit- 
ing of sour-smelling milk in children. 

Merc. SoL or Vivus. — Stools green mucus, bloody mucus, 
green, slimy, bloody, frequent scanty, corrosive ; worse at night 
and in very hot weather ; violent and frequent urging before 
stool ; nausea ; chilliness ; pinching and cutting colic ; open 
fontanels ; large head ; gums swollen and bleed easily ; tongue 
swollen, soft and flabby ; impressions of teeth on tongue ; tongue 
coated white or yellowish ; increase of saliva or intense ptyal- 
ism ; violent thirst ; frequent desire to urinate ; restless sleep ; 
sour-smelling perspiration ; jaundice. All symptoms intense. 

Pulsatilla. — Stools greenish, bilious, watery, offensive, cor- 
rosive, involuntary ; worse at night ; after measles ; after cold 
drinks ; rumbling in bowels before stool ; bad smell from 
mouth ; saliva increased ; flatulent colic ; aversion to fat, to 
meat, to bread, to milk. 

Rheum. — Stools mucus and fecal, sour-smelling, fetid ; worse 
after eating; worse during dentition; before stool, colic and 
urging ; restless ; demanding things with vehemence and crying ; 
desire for various kinds of food which become repugnant as 
soon as tasted ; restless sleep with tossing about, crying out, 
and twitching of muscles of the face and hands (bell.) ; sour 
smell of the whole body. This last symptom is very charac- 
teristic. 

Rhus Tox. — Stools watery, thin red mucus, thin yellow 
mucus, bloody ; involuntary — especially at night while sleep- 



CHOLERA INFANTUM. 193 

ing ; fetid, frothy, painless and odorless ; relieved by bending 
double and when lying on the abdomen ; better from warmth and 
from continued motion ; cutting colic ; urging ; nausea ; restless- 
ness ; pale, sunken face with blue rings around the eyes ; tongue 
dry, red or brown and cracked ; increase of saliva ; loss of appe- 
tite ; much thirst, which is worse at night ; thirst for cold 
drinks, especially for milk, which is taken greedily; trouble- 
some dreams of vivid character — of hard work and difficulty. 
This craving for cold drinks and the laborious dreams are very 
characteristic. 

Cholera Infantum. — Cholera infantum or cholerine is the 
most serious, although by no means the most common, of the 
diarrheal diseases of early life. Like entero-colitis, it is essen- 
tially a disease of the city, and is found in the alleys rather 
than on the avenues. It is most prevalent during the " heated 
term," although I have seen two fatal cases in this city, as early 
as April. Its onset is sometimes sudden and without premon- 
itory symptoms. This, however, is the exception. More 
often there is a preceding diarrhea lasting from a few days to a 
week or more. This prodromal diarrhea is usually of mild 
type and attracts but little attention. The disease itself is 
encountered most frequently in infants under eighteen months 
of age, and the majority of cases are under a year old. 

Symptoms, — The development of choleraic symptoms is sud- 
den and frequently of such severity that the case terminates 
fatally in a few hours. The two essential features of the disease 
are vomiting and purging, and either of these symptoms may 
precede the other or both may appear simultaneously. The 
vomiting is persistent and incessant. The vomited matter con- 
sists at first of whatever food has been recently taken and, after 
this has been ejected, of serum, mucus and bile. The thirst is 
unappeasable, and yet whatever is taken into the stomach, 
whether food or drink, is instantly thrown up again. At the 
very commencement of the disease the temperature rises, and in 
fatal cases may speedily reach as high as 105° Fahr. or even 
higher. In milder and hopeful cases, the thermometer does not 
register above 102° or 103° Fahr. when taken per rectum. In 
fatal attacks, the temperature has been known to rise just before 
death as high as 108°. Either of the temperatures mentioned 
may be present while the surface of the body feels cool to the 
touch, with a clammy skin and cold extremities. The stools 
are frequent, large and watery. At first the discharges contain 
traces of fecal matters and mucus, especially if the attack has 
been preceded by gastro-intestinal irritation,but quickly changes 
to the appearance of dirty water. Still later the passages lose 
D.C.— 13 



194 THE DISEASES OF CHILDREN. 

all color and become altogether serous in character. They are 
frequently so thin and copious as to soak through the napkin 
and saturate the bed. 

As they lose color they gain proportionately in odor, the 
smell being in some cases overpowering. Occasionally, how- 
ev^er, cases are met with in which the stools are odorless. In 
some attacks as many as twelve or fifteen stools may occur in 
half a day. With this copious loss of fluids there is correspond- 
ing loss of weight and strength. There is no other disease of 
childhood in which this feature is so marked. Baginsky records 
a case in which the loss of weight was three pounds in two 
days. From the beginning the general prostration is great. 

The fontanels are depressed ; the face becomes pale and 
pinched, and the eyes are sunken in their sockets. There is at 
first great restlessness, with cries and moans, and the features 
express the greatest anxiety. As the disease progresses, this 
condition gives way to one of apathy or stupor. The pulse is 
always accelerated and may beat as fast as 150 or 200 in the 
minute. The respirations are somewhat quickened from exhaus- 
tion, but are otherwise normal. The urine is scant on account 
of the great loss of fluids through the bowels. Notwithstand- 
ing the severity of other symptoms, the infant does not seem 
to experience any abdominal pain or tenderness. In fatal cases, 
the vomiting — and sometimes the diarrhea also — ceases for 
some time before death, which is foreshadowed by the absent 
pulse, the hyperpyrexia, the cold and clammy skin ; by stupor, 
coma and convulsions. In contradistinction with such cases as 
these, some infants pass into a state of collapse, which is indi- 
cated by sub-normal temperature, pinched features and cold 
breath. When these symptoms are present, death is not far 
away. 

The duration of cholera infantum depends largely upon the 
severity of the attack. In some cases death takes place in a few 
hours. In others, which terminate fatally, life is prolonged for 
several days. In cases which recover, the severe symptoms 
w^hich we have just described rarely last for more than a day, 
before signs of improvement are visible. The cessation of vom- 
iting is generally the first of these hopeful signs, after which the 
stools become less frequent and contain more solid matter. The 
color of the discharges becomes more normal. The tempera- 
ture falls and the child becomes less nervous. Restful sleep is 
a symptom of the most favorable character. The diarrhea now 
partakes more of a catarrhal character, and this may continue 
for a week or more. Relapses are not uncommon, and even 
after all signs of improvement have continued for several days, 
the choleraic discharges return with generally fatal results. In 



CHOLERA INFANTUM. 105 

other cases a diarrhea, precisely Hke that of severe entero-colitis, 
supervenes. The serous discharges cease and are replaced by 
those of a brown, gray or greenish color, containing mucus and 
undigested food, and are more or less offensive. There is a 
return of appetite and a more restful condition. Some fever 
continues and there is a persistent though less rapid loss of 
flesh. These symptoms, with exacerbations and remissions, 
may continue for an indefinite time before convalescence is 
firmly established. 

Diagnosis. — There is usually no difficulty in diagnosticating 
this disease. The frequent and profuse discharges, which rap- 
idly lose all color as well as consistence ; the incessant vomiting 
and inordinate thirst ; the rapid emaciation, which in well- 
marked cases seems to progress visibly under your very eye ; 
the pallid and anxious countenance; the extreme nervousness; 
the rapid rise in temperature — these are symptoms which 
attend no other disease and stamp its character as plainly and 
as clearly as symptoms can. True Asiatic cholera is the only 
affection with which it is possible to confound it, and when 
this is prevalent, the differential diagnosis is difficult, if not 
impossible. 

Prognosis. — Age, season of year, previous physical condition, 
environment, all tend to modify the prognosis in cholera infan- 
tum. The younger the infant, the more rapid is the exhaus- 
tion, and the less is the vital resistance to the shock of the dis- 
ease; the more humid and hot the atmosphere, the less help 
can we expect from the eliminating function of the skin. The 
violence exhibited by the early symptoms, is generally contin- 
ued throughout the attack, and when this is extreme, the 
strongest constitution is frequently unable to withstand it. 
There are cases that are fatal from the beginning, and no treat- 
ment, however skillful or prompt, is of any avail. This fact 
should not discourage the physician from employing all of his 
resources, and from hoping for good results, even under the 
most adverse circumstances. The symptoms that are espe- 
cially perilous are uncontrollable vomiting ; a body temperature 
exceeding io6° or 107° Fahr., or a sub-normal temperature of 
sudden development ; profound nervous depression, as indicated 
by stupor or coma. Favorable symptoms are a falling temper- 
ature, if it has been previously abnormally high ; or a rising 
one, if it has been sub-normal ; quiet sleep, if accompanied by 
an improvement in the pulse and cutaneous circulation is of 
the best augury. While the symptoms may be such as to 
necessitate a guarded prognosis in a given case, there are no 
cases so grave that the physician may not console himself and 
the friends with that maxim which should never be forgotten 



196 THE DISEASES OF CHILDREN. 

or ignored, In treating the affections of infants and children, 
"While there is life, there is hope." 

Treatment. — There are two requisites in the successful treat- 
ment of cases of cholera infantum, which must ever be borne 
in mind, viz., zuar?nth and stiimilation. The first can be secured 
by the use of hot-water bags or bottles, distributed about the 
patient, in addition to swathing the body in hot flannels. The 
second necessity of the case can be best accomplished by 
hot-water enemata. For this purpose the water used should be 
small in quantity and as hot as can well be borne. In case the 
stomach is more intolerant than the rectum, the latter may be 
used for purposes of medication, the indicated remedy being 
added to each enema. In the early stage of the disease the 
tongue is usually moist, and medicine may be given on the 
tongue dry, with less danger of exciting vomiting than when 
given in liquid form and swallowed. To allay the burning 
thirst, a piece of ice, wrapped in a piece of linen, may be given 
the child to suck. Water should be given very sparingly, if at 
all. Champagne is sometimes retained and may be useful, but 
better still is a little hot water with a few drops of brandy or 
whisky added. Koumiss given cold, is generally taken with 
avidity on account of the thirst. Raw-meat juice is especially 
valuable by reason of the concentrated character of its nutritive 
qualities. 

As soon as convalescence is established, its progress may be 
hastened by daily Inunctions of oil. For this purpose, plain 
olive oil may be used, or, if preferred, cod-liver oil. My friend, 
Dr. N. F. Cooke, now deceased, used to advocate the use of a 
hot bath of chicken-broth, followed by an inunction of the skin 
with cocoa butter, scented with a little almond oil. Some of 
the leading druggists here in the city keep this prepared and 
dispense It under the name ''Unguentum Graecorum." Cam- 
phor stupes applied over the abdomen are recommended by 
some as being both stimulant and soothing in their effect. 

During convalescence, hygienic treatment is of the utmost 
value. A change of air, either to the seashore or the moun- 
tains, will prove most advantageous. A short trip into the 
country will be beneficial ; but a journey by boat, even on 
fresh water, where the air is cool and invigorating, is still 
more so. 

Medicinal Treatment. — The first remedy to be thought of in 
these cases is : 

Veratrum Alb. — It is indicated by the profuse and watery 
stools ; the incessant vomiting ; the cold and clammy condition 
of the skin ; by the sudden onset of the attack ; by the great 
thirst which only provokes further emesis, and by the great 



DTSENTERT. 197 

prostration which threatens collapse. The tongue is cold, the 
pulse almost imperceptible and the countenance hippocratic. 

Arsenicum. — Stools green, watery, offensive ; vomiting imme- 
diately after anything is swallowed ; great thirst, but no satis- 
faction from drinking ; great restlessness and irritability ; cold 
extremities ; distended and tympanitic abdomen, or abdomen 
retracted and wrinkled. 

Cuprum. — Stools green and painful; retching; violent but 
ineffectual efforts to vomit. Especially indicated where there 
is a tendency to convulsions from the beginning ; hydrocepha- 
loid condition ; stools frequent, but not very copious ; eyes 
deeply sunken with blue rings around them ; violent colic and 
cramps ; cramps in the legs and feet ; general convulsions, with 
continued vomiting and violent colic. 

Camphor. — Great prostration with little or no vomiting and 
purging; coldness with threatened collapse; attack very sud- 
den ; face pale, livid, purple ; upper lip drawn up exposing the 
teeth ; foam at the mouth ; eyes sunken and fixed ; cold sweat 
on the face ; great sinking and collapse, sometimes without 
stool. 

Ipecac. — Nausea and vomiting predominate ; stools green as 
grass, or fermented like yeast ; face pale and sunken ; flatulent 
colic ; sleeps with eyes half open. 

Argentum Nitrate. — Stools green mucus, frequent and fetid ; 
painless, accompanied with much noisy flatus ; burning in stom- 
ach ; child cries for sugar and will take nothing else ; nausea, 
with loud eructations ; chilliness. The principal characteristic 
of this remedy is, that it occurs in children inordinately fond 
of sugar and sweet things, and who clamor for them even when 
sick. 

See also podophyllin, ferrum phos., kreasote, phosphorus, 
tartar emetic, ethusa, secale corn, and phosphoric acid. 

DYSENTERY. 

This disease, which is often referred to as "bloody flux,'* 
is so much more common to adults than to children that it 
scarcely deserves a place in a work like this. A few words, 
however, on the subject may not be out of place, since the 
disease, while rare, is occasionally met with in infancy and 
childhood. When it does thus occur, it is almost always 
in combination with one or the other affections already de- 
scribed. In very rare cases, however, it may occur idiopath- 
ically, and when it does so it has all the symptoms and charac- 
teristics which appertain to it in the adult. 

It affects principally the rectum and lower portion of the 



198 THE DISEASES OF CHILDREN. 

colon, the mucous membrane of which becoming inflamed or 
ulcerated, gives rise to pain, tenesmus and passages of a muco- 
purulent character. It is an acute febrile disease, usually of 
short duration, and is sometimes met with as an epidemic 
extending over large districts. In some portions of the country 
it is said to be endemic. It is more often sporadic, and may 
follow measles as a sequela. According to Condie, a few days 
of cool, rainy weather occurring in the summer, will often 
cause the prevailing bowel complaints of children to assume a 
dysenteric character. It is extremely rare in early infancy and 
never occurs in children at the breast. The onset is sometimes 
abrupt and sometimes gradual. In the former case the temper- 
ature may quickly rise to 104° or 105° Fahr., while in the latter 
there may be no elevation of temperature whatever. There 
may be severe nervous disturbance with delirium, but no vom- 
iting, as a rule. The discharges consist of almost pure mucus 
or mucus streaked with blood, and sometimes of pure blood. 
There is considerable tenesmus, which is accompanied with 
griping pain. The stools are small and frequent, sometimes as 
often as every half-hour. When this is the case, the loss of 
body weight and prostration are rapid and sometimes extreme. 
Prolapsus ani, as a result from straining, is not uncommon. 
The disease in sub-acute cases is very apt to assume after a time 
the symptoms of an ordinary entero-colitis and run a slow and 
indefinite course, attended by frequent relapses and an uncer- 
tain outcome. 

Symptoms. — These are sometimes so similar to those already 
described under the head of entero-colitis that there is difficulty 
in some cases of making a satisfactory differential diagnosis. 
Ordinarily, however, the afTection is readily recognized. The 
absence of vomiting is marked. There is more pain, and the 
pain is accompanied with uncontrollable tenesmus. The dis- 
charges, after the first one or two, cease to be fecal and are 
mucus or consist of blood and mucus. The fever is less high 
and there is but little thirst. 

The prognosis is usually good, except in cases of broken 
health from other causes, and where the disease sets in with 
exceptional violence. 

Treatment. — But little need be said regarding treatment in 
addition to that given to other forms of bowel trouble. The 
same hygienic and auxiliary measures already advocated 
are equally admissible here. The remedies whose charac- 
teristics have already been given may also be consulted. 
The two following remedies, however, have a special applica- 
tion to dysentery, and when indicated will be found of great 
value. 



DTSENTERT. 199 

Merciirius Cor. — Stools consist almost wholly of blood ; urine 
hot, scalding, bloody, scanty or suppressed ; much vesical 
tenesmus. 

RJius Tox. — The stools are mucus rather than bloody, and 
often assume an appearance like the scrapings of raw beef ; 
involuntary stools; pains in abdomen and limbs are worse 
when patient is quiet and better from moving about ; worse at 
night and particularly after midnight. 



CHAPTER V. 

CONSTIPATION. 

Definition. — The terms diarrhea and constipation are only 
used relatively by intelligent people. During infancy and 
childhood, the number of daily evacuations from the bowels 
differs with different children and varies considerably in the 
same child. This difference may be quite marked without 
being in any sense pathological ; but when there is an interval 
of twenty-four hours between evacuations in an infant under 
three months of age, or a much longer interval than this in 
older children, a constipated condition may be said to exist. 
In early life the digestive function is much more active than at 
a later period, and the digestive process is not complete until 
the egesta are duly and naturally expelled. The alimentary 
canal is the great sewer of the body, and upon its permeability 
and normal activity depend the health of the entire organism. 
A mechanical closure of the bowel, whether congenital or 
acquired, is always inimical to life. With cases of imperfect 
bowel or mechanical obstruction of accidental cause, we have 
nothing to do, since they are treated of in works on surgery. 
It is with cases of functional deficiency or inefficiency, by 
reason of which the bowels fail to act with normal and neces- 
sary frequency, that we have here to deal. 

Frequency. — The fact that diarrhea is so very common in 
early life would lead one naturally to infer that constipation — ^ 
its opposite — would be equally common. But such is by no 
means the case. In our own experience, it is very uncommon 
indeed, and when it does occur, it is so obviously due to errors 
in diet, that all the treatment that is usually necessary is to 
change the diet, to effect a cure. Our own experience, how- 
ever, is evidently exceptional, for nearly all writers on Pedol- 
ogy assert that constipation is very frequent among children. 
The physiological action of the colon — which is the portion of 
the bowel chiefly involved in constipation — requires a certain 
amount of stimulus which comes from fecal accumulation. 
This fecal accumulation is partly the refuse products of diges- 
tion, and partly the effete matters which come from incessant 
tissue waste. Constipation results when the peristaltic action 
(200) 



C OA'S TIP A IT ON. 201 

of the bowel fails to carry along these matters to their natural 
outlet. Such a condition may be due to atony of the bowel, 
which follows over-stimulation from too coarse food or the use 
of purgative medicines. The first effect of such food or medi- 
cine is to produce what might be styled a traumatic diarrhea, 
and the reactive or secondary effect is constipation. It ought 
not to be necessary to say — certainly not to students and practi- 
tioners of homeopathy — that purgatives and laxatives should 
never be given to children to relieve functional disturbance of 
the bowels. The most obstinate cases of constipation that 
come under the physician's care are of this kind. Castor oil, 
castoria, calomel, rhubarb, and all that class of remedies for 
constipation should be relegated to the past. They are Avorse 
than useless, for the more they are taken, the more will they 
be needed. Even old-school authorities have learned better 
than to advocate them. When a condition of atony exists, 
such as is here indicated, no matter how it has been produced, 
more or less impaction of the colon is the result, and the stools 
when ultimately voided are dry, hard and painful. 

One of the chief causes of constipation in infancy is the lack 
of sufificient fluid in the system. The food is given too thick 
or too little drink is given in addition to the food. Infants 
often cry from thirst when their desire is mistaken for hunger. 
When too young to talk or express their wants, drink should 
be offered to them several times daily. It will often be found 
more acceptable than food. Another of the causes of consti- 
pation in infancy is deficient intestinal secretion, due to gland- 
ular inactivity or to some fault of the mucous membrane itself. 
In either case the result is the same. Deficiency of bile causes 
fermentation and fills the bowels with gas, which in time causes 
a qiiasi paralytic condition of the bowels from distension. All 
quieting medicines, such as soothing syrups, cordials, etc., con- 
tain some form of opium, which is always constipating and 
should never be used in the nursery, if for no other reason than 
this. Certain diseases of the nervous system are well known to 
be attended by constipation as one of their prominent symp- 
toms. Thus meningitis, myelitis and hydrocephalus are diag- 
nosticated. *' The bowels are sluggish in all diseases of the 
cerebro-spinal system, due in part to the interruptions in the 
motor nerve-currents, or to a state of tonic contraction in the 
abdominal and intestinal structures." In all cases where no 
movement of the bowels occurs soon after birth — say within 
twenty-four or thirty-six hours — the anus should be inspected 
to ascertain if it be pervious or not. 

In nurslings, after excluding congenital defects, we should 
look to the mother for the cause of constipation. If she is of 



202 THE DISEASES OF CHILDREN. 

constipated habit, that should be corrected and her diet be so 
arranged as to ensure a regular daily stool. 

Treatment. — Only in exceptional cases are medicines or 
drugs necessary to cure constipation in infancy. Immediate 
relief can nearly always be secured by the use of warm-water 
enemata. These need not be large for young infants. Usually 
two to four fluidrachms are sufificient. Their efficiency is 
increased by the addition of glycerine in the proportion of one- 
half glycerine to one-half water. Suppositories of soap, gluten, 
or glycerine are also useful and when judiciously employed do 
no possible harm. They generally produce an immediate action 
and should therefore be used at the time when the child has 
previously had its habitual stool. Regularity in the action of 
the bowels is very essential. Many cases of constipation are 
due entirely to carelessness. The bowels can be educated, with 
a little care, to act with the regularity of clockwork. As soon 
as a child is able to walk alone, or even earlier, it should be 
taught to expect an evacuation of the bowels at a certain time 
of day, and when this time comes it should be placed on a chair 
suitable for the purpose. Nothing should be allowed to inter- 
fere with this regularity of habit. Older children may establish 
the habit, even when the bowels are sluggish and irregular, by 
drinking a glass of cold water a little time before a stool is 
desired. 

Excess of water, i. e., more than is needed by the system to 
maintain the secretions and the due fluidity of the blood, when 
taken into the stomach does not enter the general circulation 
or pass off by the kidneys, but goes into the bowels to moisten 
the excreta and facilitate their expulsion. 

Massage of the abdomen is also useful and may be employed 
with infants of any age. In obstinate cases, where such meas- 
ures as have been suggested prove inadequate, electricity will 
be found helpful. The faradic current is the one we have 
mostly employed. 

The main dependence, however, in the treatment of consti- 
pation should be on diet. This should depend on the age 
of the child, but in all cases should consist of food of coarser 
quality than required or admissible under other circumstances. 
Starchy foods should be avoided for reasons already given. 
Concentrated aliment, such as eggs and cheese, are very con- 
stipating in their nature. For children over two years of age, 
oatmeal with a little molasses on it may be given, and this 
may be changed to mush made of entire wheat or unbolted 
flour, or corn meal. Stewed fruits or baked apples are laxative 
and may be given to children who are having a mixed diet. 

For bottle-fed infants there is no food so well adapted for 



C ONS TIP A TI ON. 203 

regulating the bowels as Liebig's dextrinized food. This is a 
food prepared, as we have before stated, from wheat flour 
mixed with malted barley. Under heat, the starch of these 
cereals is transformed into glucose, which has decided laxative 
properties, especially when administered without milk. This 
is one of the reasons, and the principal one, why we are so 
partial to Mellin's food for infants. It is prepared after the 
Liebig formula, and by varying the proportions of milk, when 
preparing it for a meal, it can be made laxative or otherwise at 
pleasure. Prepared with water or cream, it can be given 
freely to a constipated infant with good effect ; but when the 
bowels are sufficiently loose, it should be mixed with boiled 
milk in due proportion, and with a little experience and judg- 
ment the evacuations can be regulated to a nicety. A pure 
milk diet — that is, consisting of cow's milk exclusively — is 
almost certain to result in constipation sooner or later. 

Post-mortcvi examinations of the intestines of milk-fed 
infants often show the colon coated on its inner surface almost 
to occlusion with undigested or partially digested casein, which 
has been accumulating in this locality for an indefinite period. 
For this reason it is well to occasionally give to infants at the 
breast, if constipated, an occasional feeding of thin Mellin's 
food, which acts as a diastase on the casein and carries forward 
the digestive process, in such cases as those just mentioned, to 
perfect completion. 

It seems superfluous, after what has been already said about 
the success of hygienic and prophylactic treatment in consti- 
pation, to add anything in the way of medication. But some- 
times there are concomitant symptoms that require attention, 
and medicines may afford relief in cases in which a change of 
diet may effect a permanent cure. The following remedies may 
be consulted : 

Bryonia. — The stools are very dry, as if burnt, and of a dark 
color ; alternation of constipation with diarrhea ; soreness of 
stomach and head ; dry lips and mouth. 

Graphites. — The stools are of an uncommon size, very large, 
and the child has more or less humid eruption over the body, 
behind the ears, on the face, or in the groins. 

Nux 'Vomica. — This is the chief remedy for constipation, and 
is especially valuable in the gastric derangement, which often- 
times accompanies it. In cases where it is indicated, the 
stools are large and difficult ; they are dry and hard, or small, 
frequent and painful ; much colic. 

A somewhat empirical practice, but one indorsed by suc- 
cessful experience, is to give sulphur at night and nux vomica 
in the morning. 



204 THE DISEASES OF CHILDREN, 

Colic : Enteralgia. — By giving a paragraph to this affec- 
tion, it is not intended to dignify it with the title of disease, for 
such it is not. It is never more than a symptom, and yet the 
pain which accompanies it, may be so severe as to cause con- 
vulsions or even death. It is very frequent during the first few 
months of life, and may be produced by causes so trifling that 
their nature may elude the closest investigation. 

Some children seem to have been born colicky, for, do what 
you will, the paroxysms recur again and again. As a rule, how- 
ever, colic is a result of indigestion and is a common result of 
constipation. This is not always the case, for enteric colic may 
be present when the bowels are regular or more frequent than 
natural. There is a prevalent idea that certain articles of food 
partaken of by the mother tend to produce colic in the nursing 
infant, and there seems to be good ground for this belief. 
These foods are mainly acid fruits and certain vegetables, well 
known to produce flatulence when taken into the average stom- 
ach. Theoretically, when vegetable acids are taken up by the 
blood, they are converted into carbonic acid, which speedily 
combines with soda and potassa to form alkaline carbonates. 
Physiological chemistry teaches that this is their ultimate goal, 
and teaches it without qualification or reservation. 

In a perfectly healthy organization, with digestion quite up 
to the physiological standard, this is doubtless true, and when 
it is true, acids may be eaten by a nursing woman without fear 
of being disturbed by colic in her nursling, for long before 
these acids could reach the milk glands their acidity would be 
destroyed. 

But perfect digestion is not always enjoyed by the mother or 
nurse, and the best regulated digestion will sometimes go wrong, 
in which case the fruit acids may not be entirely transformed 
into alkaline carbonates, but reach the breasts in an unchanged 
or partially changed form, and colic may be the result. 

Experience is the best guide, and a nursing woman should 
avoid those articles of diet that she feels uncertain about di- 
gesting easily. If any particular food gives her infant cohc, 
she should thereafter abstain from it, whether she craves it or 
not. There are other articles in plenty, that she may eat as a 
substitute, about which there can be no question. 

When colic does occur it is usually indicative of disordered 
digestion, for it is rarely present when digestion and assimilation 
are carried on properly. This is clearly demonstrated by the 
character of the stools, which are usually, under these circum- 
stances, either green and accompanied with mucus or filled with 
small masses of undigested curd. 

In older children, colic is often caused by eating unripe or 



COLIC: ENTERALGIA. 205 

indigestible fruit, such as green apples or gooseberries, or drink- 
ing large quantities of cold water when the stomach is empty, 
or the body overheated. Worms in the bowels, or intestinal 
obstruction from any cause, are capable of causing the disorder. 

The causes of colic are so various, and cover so wide a range of 
danger — from a trifling and transient flatus to intussusception — 
that it should never be treated lightly or carelessly. In most 
cases the affection is paroxysmal, easily palliated, and unat- 
tended with peril. Its victims, although in an agony of pain 
while the paroxysm lasts, grow and thrive as if entirely well. 
In some families with a large number of children, it is so uni- 
form in the experience of each child as to seem like a matter of 
inheritance. 

In these cases, no changes in the food supply seem to make 
any special difference in the frequency or severity of the at- 
tacks, and the inevitable conclusion is reached, that the trouble 
is neurotic, being devoid of fever, tenderness or other evidences 
of inflammation. It is a mild neuralgia of the intestinal tunics 
and as such may be periodical in its visitations. 

Infants who are prone to have colic usually develop the ten- 
dency during the first few days or weeks of life, and such cases 
continue to suffer at intervals until the process of teething is 
well advanced, or until the age of eight or nine months is 
reached. If the first month of infantile life is passed without 
colic, the exemption is usually permanent, except as due to 
dietetic irregularities or excess. 

Symptoms. — Attacks of colic usually begin suddenly and 
may even awaken the infant out of a sound sleep. The child 
draws up the legs and instinctively bends the body forward to 
relax the abdominal muscles. There is violent alternate flex- 
ing and straightening of the lower extremities, tossing and con- 
tortion of the entire body, thrusting the clenched fists into the 
mouth. There is usually more or less flatulence, but the suf- 
fering may be intense, without any distension whatever, and 
even with retraction of the umbilicus. 

Sometimes temporary relief is experienced by laying the 
child across the lap, producing steady pressure over the abdo- 
men ; while at other times the child seems to feel relief from 
being jumped up and down, which probably moves the gas 
about from place to place. When the abdomen is distended 
with flatus, it is not equally so ; it may be conical along the 
center, and the small intestines be more involved than the 
colon ; but more often the seat of disturbance seems to be in 
the large bowel, and the pain is in the direction of the transverse 
colon. In addition to the symptoms just enumerated, the 
child shrieks out with pain, the angles of the mouth are drawn 



206 THE DISEASES OF CHILDREN. 

down and the face is pitiable to see. Syncope and convulsions 
may happen in severe cases. The paroxysms may last from a 
few minutes to several hours, and may recur at stated periods 
for days together. The appetite is oftentimes unimpaired and 
the child takes food eagerly or even greedily. It also sleeps 
well when not suffering from an attack. 

Notwithstanding the torture which the child undergoes, its 
general health may not suffer in the least. It will grow strong 
and fat without showing the slightest evidence of general ill- 
health. The affection is to be distinguished from peritonitis and 
from inflammation of the bowels, by the suddenness of the 
attack, the violence of the pain, and the freedom from suffering 
between the paroxysms; by the quietude of the pulse, the 
absence of fever, and the relief obtained from pressure. Chil- 
dren will often, when pale with agony, throw themselves across 
a chair to obtain the relief which pressure affords. 

Treatment. — Before active measures are instituted for the 
relief of supposed colic, it is always well to examine the infant's 
clothing, for many a case of enteralgia has been promptly re- 
lieved by finding a pin that had been piercing the infant's 
anatomy. The palliative measures that are mostly to be de- 
pended upon are enemas of hot water, hot fomentations applied 
to the abdomen, or the hot bath. A drink of hot water is also 
very serviceable. Gin and brandy are never required, and 
when given do more harm than good. The remedies which are 
more commonly called for are colocynthis, chamomilla and nux 
vomica, and their value is in the order named. In cases of 
great pain, coupled with obstinate constipation, plumbum will 
often afford prompt relief. Other remedies may be needed,, 
but their selection will depend on concomitant symptoms that 
cannot here be anticipated. 



CHAPTER VI. 

INTESTINAL PARASITES. 

Worms. — Twenty-one different kinds of animal parasites 
have been found to inhabit the intestinal canal of man. Many 
of these, however, are of microscopical size and produce symp- 
toms of such indefinite character that they are scarcely worthy 
of notice. Others, again, are only found in distant lands among- 
savages or semi-civilized tribes, and are therefore only of interest 
to the helminthologist or the collector of medical curios. Only 
somie seven varieties of intestinal worms are known to sustain 
a causative relation to certain pathological states, which give 
them special interest to the pedologist or the general practi- 
tioner of medicine. These are the ascaris lumbricoides, or round 
worm ; the oxyuris vermiculosis, or thread worm ; the bothrio- 
cephalus latus, and three species of tenia, or tape worms ; 
and the trichocephalus dispar, or whip worms. The trichina 
spiralis is not included above because it rarely molests children. 

Any of these parasites may exist for a time in the alimentary 
canal without giving rise to symptoms which are apt to attract 
notice. But some of them — any of them, indeed — may attain 
such size or multiply in such numbers as to prejudice health, 
if not to jeopardize life itself. In a general way it may be said 
that " worms " are by no means as common in the human 
cloaca as people commonly imagine. In opposition to current 
belief, they are comparatively rare. Not only is this true, but 
the human system is wonderfully tolerant of all form.s of para- 
sites, and harbors them undoubtedly in multitudes of cases, 
where their presence is never suspected and when no symptom 
of their existence is appreciable. This fact, however, does not 
prove the truth of the position assumed by some pathologists 
of the last century, that *' these parasites exert a wholesome ef- 
fect upon the economy and aid digestion by increasing the secre- 
tion of mucus and promoting the peristalsis of the intestine.""^ 

On the other hand, they must be considered to be the occa- 
sional cause of serious derangement and possibly, in very rare 
instances, of death. A study of the life history of these para- 



Dr, C. AV. Earl, in " Cvclopedia of Diseases of Children." 

(207) 



208 THE DISEASES OF CHILDREN. 

sites is necessary in order to know how to treat them success- 
fully. 

The ascaris lumbricoides, or round worm, bears a striking 
resemblance to the common earth-worm of the gardens, except 
being longer, whiter in color and more tapering at the extrem- 
ities. The male is the smaller of the two sexes and is from four 
to six inches in length, while the female is from ten to twelve 
inches long. The body is firm and elastic and nearly trans- 
parent. The head is separated from the body by a circular 
depression, and has three small elevations, between which lie the 
teethe When a female ascaris is subjected to slight pressure, the 
extended ovaries may be seen hanging from the ventral surface 
like a bundle of processes. The eggs are oval in form, about 
■3^ of an inch in length, and it has been estimated that a single 
individual may contain as many as sixty-four millions of them. 
These ova do not contain a formed embryo at the time of their 
discharge, but are almost indestructible and may remain dor- 
mant for a very long period. It is supposed that in this or in 
the larval state they are taken into the stomach by means of 
uncooked food or unfiltered water. The ascaris lumbri- 
coides infests children between three and ten years of age. 
Its preferred habitat is the small intestine, but it is migra- 
tory in its nature and is prone to find its way into the 
large bowel and out through the anus. It also ascends to the 
stomach and even into the esophagus. It may penetrate the 
hepatic and pancreatic ducts, and in very rare cases, where the 
intestines have been perforated by ulceration, these worms in 
great numbers have been found in the cavity of the abdomen. 
They are rarely solitary like the tape worm, and yet, notwith- 
standing this great number of ova developed by the female, 
the number of mature ascarides is seldom over four or five. 

The oxyuris vermiculosis^ or seat worm, commonly known 
as the thread worm, or '■'■ pin worm," is the one most frequently 
found in early life. It varies in length from one to five lines, 
the female being twice as long as the male. There is a differ- 
ence of opinion among authorities as to what part of the 
colon is the preferred home of this parasite, some holding that 
it is the cecum, while others — and the weight of evidence is 
in their favor — maintain that it is the rectum and the sigmoid 
flexure of the colon. It is whitish or semi-transparent in 
appearance. The eggs are oval, and each contams a formed 
embryo. They are introduced by the mouth and hatched in 
the stomach, from whence they pass onward to their habitat 
in the large intestine. They often crawl out of the anus and 
enter the vagina or urethra, or get under the prepuce. In 
either of the latter locations they produce the most intolerable 



WORMS. 209 

itching. They occur chiefly in young children, but no age is 
exempt from their presence, They propagate with great 
rapidity ; and sometimes exist in such numbers that they hne 
the intestine Hke fur. When they are so abundant as this, 
they are found above the illeo-cecal valve as well as below it, 
and are especially numerous in the appendix vermiformis. 

The tricJioccpJialiis dispar, is of but little importance clin- 
ically, since it occurs but rarely in childhood, and it is not 
known that its presence produces any particular symptoms 
which are recognizable. It is found more commonly in the 
cecum and less often in the ileum and appendix vermiformis. 
It is sometimes called the whip worm from its shape, the pos- 
terior or thick portion of the female being bent or curved like 
the stock of a hunting whip, while that of the male is rolled in 
the spiral form. They are supposed to be introduced into the 
system by means of uncooked fruit and vegetables. 

The tape worms are by no means as common as those just 
mentioned, although they are occasionally found in children of 
all ages, except nurslings. There are several varieties of tape 
worms, the hothricephalus latus being the largest. This worm 
attains a length of from fifteen to twenty-four feet, but is rarely 
found outside of Europe, and then it is chiefly met in countries 
bordering on inland lakes and seas, where the inhabitants live 
largely on fish. The two varieties most frequent in North Amer- 
ica and Europe are the te7iia solium and the tenia saginata 
or medio caiiellata. The latter is the beef tape worm ; the former 
is the pork tape worm. The tape worm is an hermaphrodite, 
each segment containing the two sexual organs. The head or 
scolex is small, being about the size of a pin-head. The devel- 
opment of the worm proceeds from this head, segment after 
segment being produced by a sort of budding process. These 
segments are attached to each other at their extremities, and as 
they become further and further removed from the head, they 
become larger and more matured. When they have attained to 
full maturity, they are detached and enter upon an independent 
existence. Breaking the chain of segments does not compro- 
mise the life of the parasite. It continues the reproductive 
process by segmentation, and in time the former number of seg- 
ments and the original length of the chain are restored. The ma- 
ture segment, called proglottides, vary in size accordingly as they 
are in a state of contraction or relaxation. When relaxed, their 
length is about half an inch and breadth one-quarter of an inch. 
The genital organs are situated on the margin of each segment, 
a little posterior to the middle, and there is an alternation in 
their location between the right and left margins in the chain 
of segments. The uterus lies in the center of the segment, 
D. C— 14 



210 THE DISEASES OF CHILDREN. 

forming a longitudinal straight line. Several branches are 
given off from each side of the uterus, and these divide and 
subdivide like the branches of a tree. 

The male genital organs lie in the. same aperture or pore in 
the margin of the segment with which the uterus and ovaries 
connect. Abnormal development of the parasite is very com- 
mon. Sometimes two or more segments are fused together, 
and often they are stunted in their growth. Sometimes they 
contain holes, fissures and flaws, either from their original 
development or produced by rupture of the distended uterus. 

The tenia solium is nearly always found alone, whence its 
name. The French call it ver solitaire. 

At the top of the head of this parasite, there is a circle of 
booklets, and back of this circle are four sucking disks, which 
the worm is able to protrude and move freely. When protruded 
they have the appearance of small tubercles with slender pedi- 
cles. The eggs of the tenia solium are globular, with a diam- 
eter of about yIo of an inch, and with thick shells, which are 
striated '' like mosaic work " by lines which cross each other. 
It is estimated that not less than 50,000,000 eggs are contained 
in all the segments of a mature worm. 

The tenia saginata, called also the medio eanellata, is much 
larger, stronger and thicker, both as regards the head and the 
segments, than the tenia solium. It is, however, not so long, 
usually measuring not to exceed eighteen feet. It is furnished 
with four strong sucking disks, like the tenia solium ; but it 
lacks the circle of booklets which characterize the latter. In- 
stead of the booklets, the head is furnished with a small frontal 
sucking disk. There is but little difference in the sexual appa- 
ratus of the two species, but the eggs of the saginata are larger 
than those of the solium and are oval in form. The former 
occurs over a much greater area of the earth's surface than the 
latter. 

The other species of tenia do not differ from these named 
sufificiently to warrant a separate description. Their symp- 
toms and treatment are precisely alike. 

Etiology. — From what has already been said, it is evident that 
the cause of worms in children is due to the introduction into 
the system of either the ova or the larva of the worms them- 
selves, and that when these have once found a lodgment within 
the system and a suitable soil for maintenance, they grow and 
propagate according to the fixed laws of their species, each 
finding its congenial habitat. Some species, such as the ascaris 
lumbricoides, do not develop directly from the egg into the 
adult form within the body of the ultimate bearer, but require 
the intermediate assistance of some invertebrate animal, as a 



WORMS. 211 

worm or the larva of an insect, in which the egg is matured, and 
after passing through certain necessary stages of metamor- 
phosis and being discharged, are received into the human 
stomach in either the food or drink. In the country, where 
the drinking water is obtained from springs or shallow wells, it 
is very easy for the water to become contaminated by excreta 
and to convey ova or embryos into the stomachs of those who 
partake of it. Uncooked fruits and vegetables, such as salads, 
are also believed to be common mediums for their dissemina- 
tion. A congenial soil is necessary, however, for their growth 
and development, and this is furnished when the vital powers 
are reduced or when the secretions are vitiated by disease. It 
has been frequently noticed that children in the last stages of 
continued fevers often pass lumbrici in their evacuations. 
Persistent indigestion, accompanied by irritation or inflamma- 
tion of the mucous coat of the intestines, with excessive mucus 
secretion, predisposes to the generation or development of 
worms. Without this congenial soil, the ova or embryos may 
pass harmlessly through the alimentary canal without effecting 
a lodgement and of course without propagating. This ac- 
counts for the fact that some children are notoriously '* wormy," 
while others are never thus troubled. Cleanliness has also 
much to do with the matter. Those who go unwashed and 
never clean their finger-nails, or who live in almost total disre- 
gard of sanitary requirements, are especially liable to worms. 

Symptoms and Diagnosis. — All sorts of symptoms have at one 
time or another been ascribed to worms. They have mostly 
been nervous, such as convulsions, epilepsy, cramp, choreic 
movements, or nightmare, and have been supposed to be due 
to some reflex nervous discharge set going by the local irritation. 
But it is very doubtful whether any are of diagnostic impor- 
tance. The presence of worms can only be diagnosed with cer- 
tainty by finding them or their ova in the evacuations or about 
the anus. The habit of picking the nose is the popular indica^ 
tion, but it is often no indication at all. Pruritus ani is of more 
value, and when it is observed should always lead to a careful 
inspection of the feces, and even to the use of enemata with 
the view to detecting the worms themselves. Other symptoms, 
such as irregularity of pupils, discoloration round the eyes, tu- 
midity of the abdomen with colicky pains, diarrhea, variability 
of appetite, etc., only need mention to show that they can have 
no special significance, although they may probably be some of 
the many symptoms of feeble health, impaired digestion, and 
irregularity of the bowels, which are often present where worms 
abound. The ascaris lumbricoides, however, inhabiting, as it 
does, the small intestine, and often in large numbers, is apt to 



21 f? THE DISEASES OF CHILDREN'. 

wander into the stomach, and is sometimes associated with 
very acute symptoms. Sudden attacks of fever and vomiting- 
are apt to supervene, and to assume even an aspect of a bad 
form of gastritis or of severe cerebral disease. The round worms 
would seem to be particularly prone to induce convulsions. 
Nor need we wonder that such is the case, inhabiting the in- 
testine, as they may do, by hundreds, and at a time of life when 
the nervous system has not yet reached the stable condition it 
assumes in healthy adult age. Dr. West has, however, seen 
very severe convulsions with thread worms, and other authors 
have equally noticed the liability to nerve disturbances which 
exist with the tape worm. 

Thread worms, collecting in great numbers in the rectum, are 
apt to excite local irritation, mucus diarrhea, prolapsus ani, 
and the occasional passage of blood from the bowels. In the 
male they may excite priapism, and some of the symptoms of 
stone. Frequent micturition is a common symptom of their 
presence, and I have occasionally noticed hematuria also, and 
the uneasy sensations about the genital organs may induce the 
habit of masturbation. 

In the female a purulent discharge from the vagina, due to 
worms that have migrated from the anus, is by no means un- 
common. Worms of any kind are liable to occasion a mucus 
diarrhea, associated with a good deal of tenesmus. 

Tape worms give rise to fewer local symptoms than either 
of the other varieties of parasites ; but they are often associated 
with progessive and marked emaciation. In a general way, it 
may be said that there are no symptoms of worms that are path- 
ognomonic — no symptoms, indeed, but may come equally well 
from any other cause producing irritation of the stomach and 
bowels. Only when worms pass from time to time, or when a 
microscopical examination of the feces has revealed the pres- 
ence of ova, can we determine positively that the symptoms 
result from their presence. 

An exception might be made to this statement in the case of 
pin worms — oxyuris vermiculosis. These worms can often be 
seen about the anus, when this orifice is subjected to close in- 
spection. This is best done shortly after the child has gone to 
bed for the night. By placing the child on its elbows and knees, 
under a bright light, and spreading the buttocks widely apart, 
the worms, if present, will be seen wriggling about in the liveliest 
manner. Considerable expedition must be used, however, for as 
soon as the worms feel the cold air on exposure, they seek the 
folds of the anus, and are quickly out of sight. 

Treatment. — It is scarcely necessary to point out to the intel- 
ligent student that in the treatment of intestinal parasites we 



WORMS. 213 

are not dealing with a simple disturbance of function, nor with 
any of the ordinary problems of pathology. 

It would be the merest folly to treat the symptoms produced 
by worms, while leaving the worms themselves undisturbed. 
The question of remedies, then, is outside the pale of medical 
dogmas, and is purely one pertaining to toxicology. When 
treating a patient for worms, the homeopathic physician is com- 
pelled to lay aside his favorite shibboleth and accept the empir- 
ical treatment which has been born of necessity and cultured 
by experience. Much harm has been done by resorting too 
early to vermicides under a misinterpretation of symptoms, 
when a careful and tentative exhibition of the indicated home- 
opathic remedy would have been far better. Such remedies in 
proper attenuation should always be given first in the absence of 
unmistakable signs of worms, and after this, if the symptoms 
still persist, the appropriate anthelmintic should be given. 

It should be borne in mind, however, that even after the par- 
asites have been expelled, a condition of the system may remain 
that renders it possible for the worms to develop again, and 
this condition must be changed before a complete and radical 
cure can be looked for. In other words, it is not alone sufficient 
to remove the worms from the intestinal canal ; we must in 
addition so alter the soil as to render it impossible for others to 
propagate. 

Hahnemann was not the only one of the older writers who 
believed that a state of system favorable to the propagation of 
intestinal parasites was necessary to their production, and that 
that state or condition was removable by medicinal agents. 

Brenner, who has the reputation of being the most celebrated 
helminthologist of his time, designated, under the name of 
diathesis verminosa, a condition of the alimentary canal accom- 
panied by disorders of nutrition and digestion, in consequence 
of which material accumulated in the intestine which was fav- 
orable to the production of worms. It was even held by such 
distinguished investigators as Rilliet and Barthez that this 
worm diathesis could exist without the presence of worms. 

Now, however, thanks to the exact scientific work done by 
patient investigators, accompanied by experiments on animals 
and man, the life history of most of the intestinal parasites, and 
the part which they play in the production of disease, have 
been put on a firm and scientific basis. 

As the different varieties of worms require different remedies 
to effect their expulsion, we shall speak of them seriatim. 

Ascaris Lumbricoides. — For these round worms our most effi- 
cient remedy is santonine, which is the active principle of cina, 
or artemisia santonica. It should be given in the evening at 



214 THE DISEASES OF CHILDREN. 

bedtime, in doses of from one to three grains in powder, in the 
form of troches or capsules, or as it is nearly tasteless, it may 
be spread on bread-and-butter. It should be followed in the 
morning by castor oil or some other efificient laxative. Dr. 
Cowperthwaite says that he has secured all of the benefits of 
santonine by giving the first or second decimal trituration four 
times daily for three or four days. He states that when given in 
this way the drug does not produce its objectionable symptoms, 
viz., disturbed vision, red urine, etc., which so frequently fol- 
low the administration of large doses. It has been our own 
practice to combine with the santonine, as above indicated, a 
powder of the second decimal trituration of mere. cor. sub., 
which obviates the necessity of giving castor oil afterwards. 

Spigelia, or pink root, is also an excellent vermicide, and 
may be given in doses of from ten to thirty minims, of the 
fluid extract. It is mostly used in an ofificinal preparation, 
combined with senna. 

Cina. — This is the crude drug, artemisia santonica, of which 
santonine is the active principle. It is of all vermicides the 
most valuable, especially for the round and thread worms. It 
is also quite homeopathic to the existing morbid condition 
whose symptoms are usually attributed to worms, whether 
they are present or not, and will remove their symptoms while 
acting as a vermicide at the same time. Special indications 
for its exhibition will be given under the head of General Thera- 
peutics, at the end of the chapter. It should be administered 
in drop doses of the tincture in a little water or on sugar every 
three or four hours. 

Oxyuris Vermicular is. — For this variety of worms, medicines 
administered by the mouth are of but little account. As has 
been already pointed out, their habitat is in the rectum and 
about the anus. For this reason they are generally reached 
most effectually by means of injections. Common salt and 
water is oftentimes all that is necessary. Infusions of fresh 
garlic injected into the rectum for a few nights at bedtime we 
have found very effectual. If used under the physician's 
personal supervision, an enema of bichloride of mercury, in the 
strength of one grain to four ounces of water, is a sure cure. 
It should not be repeated, and should be followed after a few 
minutes by an injection of plain cold water. Anointing the 
anus, and the labia vaginae when necessary, with sweet oil or 
vaseline, is of benefit. 

Tape Worms. — In the treatment of tape worms, great pa- 
tience and persistence are often necessary to secure the head. 
Unless this is secured the worm will grow again, necessitating 



TAPE WORMS. 215 

a repetition of the treatment. As it takes from ten to twelve 
weeks for the worm to develop its full length, it is often impos- 
sible to tell before this length of time has elapsed whether the 
treatment has been successful or not. It must be borne in 
mind that all of the remedies used for the expulsion of tape 
worms are more or less poisonous in their nature, and irritating 
to the stomach and bowels. They should never be used, there- 
fore, without there is good and sufficient ground to believe 
them necessary. 

Before administering the tenicide, the patient should be 
placed on a low diet for a few days, avoiding such articles of 
food as are digested in the small intestines, and only eating 
beef-tea, chicken-soup, milk, toast, or some light food which 
leaves little residuum. German physicians put their patients on 
a diet of onions, garlic and salt-herring, for the reason that 
these articles are known to be obnoxious to the worm. The 
medicine may then be administered, and after a few hours an 
active purgative given to expel the dead parasite. In case the 
head is not discharged, there is no certainty of the success of 
the treatment, but further means for its removal should not be 
employed until fragments of the worm are again discharged. 

Male fern or filix mas, is the oldest and probably most pop- 
ular tenicide. It is best administered in capsules containing 
one-half drachm of the ethereal extract. The oil may also be 
given in half-drachm doses, in mucilage with milk. 

The bark of the pomegranate root {Pzmica gra7iatiim) is an ex- 
cellent tenicide. The fresh bark only should be used. About 
one to one and a half ounces should be boiled in a pint and a 
half of water until the quantity is reduced one-half, this amount 
being taken in three doses within an hour. 

Kiickenmeister strongly advises the addition of ten or fifteen 
grains of the ethereal extract of male fern. The tannate and 
sulphate of pelletierin, the active principle of the pomegranate, 
have both been successfully used to remove the tape worm. 

Kousso, the flowers and tops of Brayera anthelmintica, a tree 
of Abyssinia, a country where the tapeworm abounds, is con- 
sidered an effective tenicide, and is much used for the species 
there prevalent. It has also been used with success in Europe 
and America. It may be given in doses of from one to two 
drachms of the powder. Heller prefers to give it in compressed 
balls or disks coated with gelatine. He considers three drachms 
necessary for the tenia solium, and five drachms for the tenia 
saginata. The balls or disks should be placed on the back part of 
the tongue and swallowed alone, or by the aid of some coffee. 
After this, the tendency to vomiting should be resisted, with 
the assistance of lemon-juice, bits of ice swallowed, and by 



216 THE DISEASES OF CHILDREN. 

maintaining the recumbent position. He advises an ounce of 
castor oil two hours later, to expel the worm speedily and en- 
tire. Koussin, an alcoholic extract, is now used by some in ten 
to twenty-grain doses, instead of the crude drug. 

Kamala, the glandular powder and hairs from the capsules 
of the rottlera tinctoria, is an efficient and not unpleasant teni- 
cide. It may be given in doses of from one to two drachms, 
prepared in a gum-arabic emulsion, and repeated every three 
hours if necessary. No purgative is required to follow. If 
two or three doses do not prove effectual, add about one-half 
drachm of the oil of male fern, and repeat. 

Pepo semen, an emulsion of pumpkin-seeds, is ranked in this 
country as one of the best tenifuges. It possesses the advan- 
tage of producing no unpleasant, injurious effects. The emul- 
sion is prepared by rubbing up about two ounces of the fresh 
seeds in a mortar with a pint of water, and straining through a 
cloth. To this ten to fifteen minims of sulphuric ether should 
be added, and the whole quantity taken at one dose, in the 
morning on an empty stomach. If the first dose is not efTec- 
tual, it may be repeated each morning for several days. 

Turpentme is an efficient tenicide, but its unpleasant taste 
and the ill effects following its use have prevented its general 
employment, save in cases which have resisted other methods 
of treatment. It may be given in one to two drachm-doses 
every half-hour until an ounce is taken. Bartholow advises 
uniting with it an equal amount of castor oil. It is probable 
that any of the medicines before mentioned are equally effec- 
tual, and less injurious to the system. 

General Therapeutic Indications for Intestinal 
Worms. — In addition to the methods suggested for the destruc- 
tion and removal of intestinal worms, our Materia Medica af- 
fords a number of remedies which have been proved valuable 
for the relief of symptoms associated with the presence of these 
parasites or which remain after their removal. 

Cina is our most important remedy. It not only covers the 
range of symptoms most often found in connection with the 
presence of round or thread worms, but containing santonine 
as its active principle, it is practically a vermicide, and frequently 
the only remedy required for the removal of the parasites and 
the symptoms they may have produced. Its chief indications 
are : child irritable and cross ; has dark rings around the eyes, 
and a sickly expression ; white and bluish around the mouth ; 
tossing about in sleep, with sudden cries ; boring in the nose 
with the finger ; grinding the teeth at night ; great hunger, or 
loathing of food ; nausea and vomiting ; abdomen hard and 



INTESTINAL WORMS. 217 

distended ; twisting, colicky pains ; itching of the anus ; turbid 
urine ; dry, hacking cough, which causes gagging; twitching of 
the muscles, and convulsive motion of the head and limbs; 
fever, usually intermittent or remittent in its character. 

Jgjiatia. — Especially in mild, nervous children. Itching and 
crawling at the anus and in rectum, as from thread worrps ; 
prolapsus ani ; epileptiform convulsions. 

Mercuriiis. — Excessive hunger; salivation ; fetid odor from the 
mouth ; abdomen hard, distended and painful ; glandular swell- 
ings ; will sometimes cause discharge of ascarides or of lumbrici 
without other aid. 

Aconite. — Worm fever. Excessive restlessness, face red and 
pale alternately ; loathing of food ; intolerable nightly tingling 
and itching at the anus as from thread worms. 

Spigelia. — Nausea every morning, better after eating ; squint- 
ing ; sensation of a worm rising in the throat, better after eat- 
ing; itching and tingling in anus and rectum. 

Sulphur. — Especially after other remedies have failed ; exces- 
sive, ravenous hunger, though the stomach feels full and dis- 
tended after eating but little ; nausea before meals, and gone, 
faint feeling about ii A. M. ; abdomen distended; itching and 
crawling in rectum and anus ; turbid urine ; emaciation and 
debility. 

Calcarea carbonica. — In leuco-phlegmatic children, especially 
where there seems to be a hereditary predisposition to worms ; 
abdomen hard and much distended ; children of a scrofulous 
habit. 

Consult also Terebinthina, Sta7i7tum, Cinchona, Ferrum, Saba- 
dilla, Urtica urens, Tcucrium (thread worm), Antimonium crud. 

For the symptomatology, diagnosis and treatment of other 
forms of intestinal parasites than those here mentioned, includ- 
ing trichina spiralis, the reader is referred to works on general 
practice. 



CHAPTER VII. 

INTESTINAL OBSTRUCTION. 

Intussusception — Definition. — Intussusception, or invagi- 
nation of the bowels, occurs when one portion of the bowel 
passes into another adjoining portion. It is not, properly- 
speaking, a disease, but rather an accident and therefore belongs 
more to works on surgery than medicine. It is, however, essen- 
tial that the student of pedology should be familiar with its 
symptoms and nature, for it is one of the most painful and 
dangerous maladies, and everything pertaining to its relief 
depends on its early recognition. 

Fortunately, it is of rare occurrence, especially in private 
practice. Rilliet and Barthez have, however, recorded twenty- 
five cases as occurring in their experience and Dr. J. Lewis 
Smith has tabulated the history of fifty-two cases. Nearly 
one-half of these cases were under six months of age. Leich- 
tenstein, who has compiled statistics of four hundred and 
seventy-three cases, says : " Half of all invaginations occur dur- 
ing the first ten years. The first year, after the third month, is 
remarkable for a special frequency — one-fourth of all intus- 
susceptions." No case under three months is recorded by 
either of these observers. 

Some curious facts relating to sex and previous condition of 
health are brought out by the statistics furnished by these gen- 
tlemen. Of the twenty-five cases collated by Rilliet and Barthez 
all but three were boys, and of thirty-four cases of J. Lewis 
Smith's fifty-two, twenty-three, or two-thirds, were boys. 
Among the latter collection one-half of the number had been 
in previous good health when the accident occurred, while the 
other half had been more or less ailing. Most of the latter had 
been suffering from diarrhea, dysentery or constipation, or 
diarrhea alternating with constipation. 

Dr. Smith therefore concludes that the two opposite condi- 
tions, namely, constipation and the diarrheal maladies, so often 
precede the displacement that they must be regarded as com- 
mon causes. He further says : " The great liability to intus- 
susception in infancy is due partly to the anatomical character 
of the intestine in this period of life, and partly, doubtless, to 
the fact, that there are more frequent irregularities in the 
(218) 



INTC'SSUSCEPTIO.X. 219 

intestinal movements than in older children. In the infant the 
walls of the intestines are thin, the mucous and muscular coats 
and the connective tissue being much less developed than in 
those that are older. The mesentery and meso-colon have also 
greater depth as compared with the same in other periods of 
life, except the meso-colon at the points where it passes over 
the kidneys, in which places it is very short or even in some 
cases nearly absent. Moreover, the space occupied by the large 
intestine, in which part of the digestive tube intussusception 
commonly occurs, is much shorter relatively to the length of 
the intestine, than in those that are older. In about thirty 
measurements which I have made of the length of the large 
intestine and the space occupied by it, the latter was found on 
the average about one-third that of the former, which of course, 
necessitates doubling of the intestine on itself. These peculiar- 
ities of structure in the infant obviously favor the occurrence 
of intussusception." 

The direction of an invagination is always downward in the 
direction of the normal peristalsis ; that is, that portion of the 
intestine which receives the other is always on the lower or 
anal side. 

In the majority of cases of intussusception occurring in 
infancy and childhood, the seat of trouble is near the ileo-cecal 
valve. Either the ileum is invaginated in the colon or the first 
part of the colon is invaginated in the part succeeding it. In 
rare instances the intussusception takes place in the small 
intestine. Sometimes there is so little constriction of the incar- 
cerated portion of the bowel that it remains pervious. In these 
cases life may be maintained for weeks or months without any 
material change in the displacement, but death ultimately takes 
place from exhaustion. 

Symptoms. — The symptoms of intussusception are very simi- 
lar to those of strangulated hernia. Instead of the obstinate 
constipation, however, which marks the latter malad)^ we have 
in acute cases, great tenesmus with blood and bloody mucus, 
extruded from the anus. 

In some part of the abdomen, corresponding to the seat of 
the invagination, we have an elongated, doughy tumor. Very 
soon after this tumor is found we have vomiting, first of food, 
if any has been recently taken, and after that mucus and blood. 
Stercoraceous vomiting occurs in only one-fourth of the cases. 

The pain is very great and is accompanied with constant 
tenesmus. There is a sudden supervention of the symptoms 
of collapse, such as pallor, sunken eyes and rapid pulse. In 
chronic cases all of these symptoms may be absent. Goodhart 
tells of a case that occurred in his practice, in which there was 



220 THE DISEASES OF CHILDREN. 

an utter absence of all signs of intussusception before death, 
and the invagination of the bowel was only discovered post 
inortejn. Usually, however, the symptoms are well marked. 
At least, there is no mistaking the fact that the child is desper- 
ately ill. The onset of the acute symptoms is sudden. Thirst is 
nearly always present and tenesmus is rarely absent. The tem- 
perature is at first normal, but very soon becomes sub-normal. 

In a large proportion of cases, a careful palpation of the ab- 
domen reveals a sausage-shaped, soft, elastic, and doughy 
tumor, which at first is not painful to the touch, but soon be- 
comes so. It varies in size from an ^g^ upward, but is rarely 
more than a few inches long. Sometimes the tumor is so low 
down in the colon that it can be felt by the finger inserted in 
the rectum. In acute cases the diagnosis is easy, but in chronic 
cases it may be attended with extreme difficulty. When the 
diagnosis is once made there is nothing to be gained, but much 
to lose, by procrastination. The most energetic measures 
should be instituted at once. 

Prognosis. — In acute cases, where the onset of symptoms is 
sudden and severe, the treatment is usually unsuccessful, and in 
from twenty-four to thirty-six hours, the child dies. But 
enough cases have terminated favorably under treatment to 
furnish ground for a certain amount of hope. In chronic cases 
strangulation, as a rule, does not occur, and the case may go on 
for weeks or months with only ill-defined symptoms. The pain 
at first is paroxysmal, and there may be long intervals during 
which it is entirely absent. Vomiting may be present or not. 
At any time, however, these chronic cases may take on acute 
symptoms, or on the other hand, may in time terminate favor- 
ably even without treatment. 

Dr. Hern calls attention to a valuable diagnostic point in 
this connection, viz. : in chronic invagination the tumor moves 
its position and gradually advances, while the tumor resulting 
from fecal impaction remains stationary. 

Treatment. — It is only in chronic cases, not attended by ur- 
gent symptoms, such as vomiting, acute pain, and threatened 
collapse, that medicine can be of any service. But in these 
chronic cases, remedies calculated to control spasms and allay 
irritability, may prove useful. These remedies are mainly Bel- 
ladonna^ Gelsemium, Colocynth, Nux vomica, and Hyoscyamus. 
No medicine having the effect to stimulate peristalsis is per- 
missible under any circumstances. 

In acute cases the treatment must be principally mechanical 
or surgical. Gentle massage of the abdomen may sometimes 
succeed in disengaging the incarcerated part ; but no great 
amount of time should be spent in the employment of measures 



INTUSSUSCEPTION. 221 

like this, which are so manifestly unreliable. Our main depend- 
ence, this side of laparotomy, must be on injections of oil or 
water, or insufflation of the bowel by means of gas or air. Both 
of these measures have been used successfully, and both appeal 
to reason and common sense. There is a difference of opinion 
as to which is better, and the record of successful cases shows 
that each has succeeded after the other has failed. 

In using water enemata, the child should rest on a pillow, or 
on the nurse's lap, with the hips elevated at an angle of 45°. 
The water should be warm, and should be gently poured into 
the bowel by means of a fountain syringe held above the patient 
sufificiently high to secure a hydrostatic pressure of five or six 
pounds to the square inch, t. c, twelve to fifteen feet. Experi- 
ments on the cadaver have demonstrated that the normal colon 
will bear a pressure of eight or nine pounds without rupturing; 
but it must be borne in mind that in a case of intussusception 
twenty-four hours, or less, may produce a gangrenous state of 
the bowel, and its resistance be thereby greatly lessened. The 
water should be allowed to flow steadily and gently into the 
gut, and not in a sudden or spasmodic jet. 

While the enema is being given, the abdomen should be 
manipulated by an assistant, so as to urge the stream of water 
into the constriction. It may be necessary in some cases to resort 
to anesthesia to secure a thorough trial of this proceeding. In 
case of failure, the operation should be repeated again after a 
few hours' rest. In using insufflation of air, a common bellows 
will answer, using the nozzle of a Richardson syringe and a 
rubber tube. The nozzle of the syringe will have to be closely 
packed about the anus, in order to prevent the outward escape 
of air. There is not so much danger of rupturing the bowel 
with air or gas as with water, but it may be well to use some 
caution, lest such an accident might happen. There are various 
appliances for generating gas for use in such emergencies as 
this, to be had of the instrument-makers ; but a description of 
them is not deemed necessary. 

When these measures have failed to relieve the invagination, 
there is but one resource left, and that is laparotomy. The 
published statistics of this operation on children are far from en- 
couraging, for they do not bear well the shock which is unavoid- 
able in opening the abdominal cavity. But cases of recovery 
after laparotomy has been performed have been recorded, even 
in children as young as six months; and after other measures 
have failed, the case is always so desperate that even a forlorn 
hope is better than no hope at all. 

The method to be pursued in the performance of the opera- 
tion belongs properly to works on surgery. 



CHAPTER VIII. 

DENTITION. 

The development of the teeth and their eruption through 
the gums marks one of the epochs or stages in the progress of 
of the infant toward maturity, and is the only one that is accom- 
panied more often than otherwise, with pain or general consti- 
tutional disturbance. It is not to be understood that dentition 
is in itself a morbid process or that it is always accompanied by 
pathological symptoms. On the contrary, the process is a 
purely physiological one, and in exceptional cases proceeds 
from beginning to end without symptoms of an abnormal char- 
acter. But these exceptions are rare. As a general thing, for 
some time before the eruption of the teeth there is more or less 
restlessness, some slight fever, irritability of the stomach, and 
diarrhea. It does not always follow that such disturbances as 
these just mentioned are altogether due to the teeth, for the 
teething period is one of great general activity, and other por- 
tions of the organism are undergoing change and evolution, as 
well as the gums. Towards the end of the first year of life, the 
follicular apparatus of the intestines is undergoing increased 
development, the cerebro-spinal system is passing through a 
stage of rapid growth and high functional activity, and most of 
the organs and tissues of the body are in a state of active 
change. The evolution of the teeth is not, therefore, a solitary 
instance of developmental progress, but corresponds to a sim- 
ilar activity of growth in other parts. It is not at all strange 
that a period of such rapid transitions should be also a period 
of exceptional susceptibility. And thus we find it to be. Dur- 
ing this period morbid impressions, which later on would soon 
be overcome, are now more lasting and serious ; and functional 
disturbances, which ordinarily would soon rectify themselves, 
easily drift into incurable maladies. 

The first dentition — or, to speak more accurately, the first 
dental epoch — begins at about the middle of the first year and 
ends towards the beginning of the third year, or when the infant 
is two years or two-and-a-half years old. The progress of den- 
tition, however, is subject to many deviations. In exceptional 
cases, the first of the milk teeth appear much earlier than the 
time above mentioned, and cases are on record of children born 
(222) 



DEN TI TI ON. 22 ^ 

with teeth. In other cases the dental epoch is delayed, and 
the entire set of milk teeth is not erupted until the child is five 
or six years old. 

Under normal conditions, the first dentition begins at about 
the fifth or sixth month, and continues with occasional pauses 
until the full twenty teeth have made their appearance. The 
teeth are inclined to erupt in pairs, those of the lower jaw pre- 
ceding those of the upper by a brief interval. Occasionally in 
precocious children a considerable number of teeth are erupted 
together, or so closely together as to be a source of danger. 

This happens often in children in the best of health, plump, 
large and rosy, but is not devoid of danger. Their plethora and 
precocity are a misfortune, for an infant at this early age, no 
matter how strong and healthy, can bear only a certain amount 
of nervous strain. 

Ordinarily the milk teeth make their appearance in the fol- 
lowing order : 

Between the fifth and seventh months after birth the two 
central incisors of the lower jaw erupt, at or about the same time. 

Between the seventh and ninth months, the two upper cen- 
tral incisors appear, followed shortly by the two lateral incisors. 

Between the ninth and twelfth months, the two inferior lat- 
eral incisors, the two upper anterior molars ; and in the two 
succeeding months, the two lower anterior molars appear. 

Between the fifteenth and twentieth months, the four canine 
teeth erupt. Between the the twentieth month and the middle 
of the second year, the four posterior, molars appear. 

The eruption of the twenty milk teeth, or as they are some- 
times called, the deciduous teeth, is now complete, and no 
more teeth make their appearance until the fifth or sixth year, 
when these teeth fall out or are forced out, to make place for 
the permanent set. The temporary teeth drop out in about 
the same order as they made their appearance. 

While the order above given is that which is usually adhered 
to, it is not uncommon for this normal sequence to be violated. 
The upper incisors sometimes erupt first, and when such is 
the case, their appearance is usually somewhat delayed. In 
rare instances, the molars or canines precede the incisors, a 
posterior molar erupts before a canine, or a canine precedes an 
anterior molar. 

With some superstitious but otherwise intelligent people, 
the eruption of the upper incisors first is considered a bad 
omen. Among some of the tribes of Central Africa, a child 
that cuts the upper teeth first is believed to be viaiko (unlucky), 
and certain to bring death into the family. Such a child is, 
therefore, sold to the Arabs. 



224 THE DISEASES OF CHILDREN. 

Symptoms and Disorders of Teething.— Shortly before 
the teeth begin to make their appearance, there is a noticeable 
increase of saliva, which dribbles from the mouth and is called 
drooling. At the same time, the infant exhibits an uneasiness 
of manner, which is referable to the gums, and which is par- 
tially relieved by rubbing them. In pursuance of this object, 
the child ''munches" with his jaws, sucks his lips and gives 
other evidences of uneasiness. His sleep is disturbed and dur- 
ing the day frequent contractions of the brow give indications 
of pain. 

Examination of the mouth reveals the source of discomfort. 
The gums are found swollen and cushiony, and shortly before 
the tooth appears are hot and tense. At this time friction, 
which before was pleasant, becomes very painful. The gum is 
evidently tender, which tenderness, however, subsides as soon 
as the tooth is through. 

The pyrexia of teething is very irregular, and subject to rapid 
variations. It is often higher in the morning than at night and 
fluctuates during the day. 

These symptoms do not always accompany immediately the 
eruption cf a tooth, but may precede it by days or even weeks. 
Nor are the symptoms steady and persistent. They come and 
go — waxing and waning in severity, and frequently subsiding 
altogether for a time, so that the child passes through alternate 
periods of suffering and ease before the tooth finally erupts. 
The sense of discomfort, of pain and general disturbance which 
the infants feel, is not usually so great at the time the tooth 
pierces the gum, as it is when the tooth is forcing its way upward 
through the dental processes which hold it securely in the jaw. 

Complications. — The symptoms just described are to be 
regarded as the natural accompaniment of dentition, and in 
themselves do not indicate anything about the process of an 
abnormal character. But oftentimes these symptoms are but 
the precursor of others more serious in their nature, and which 
are to be considered as accidental complications. They arise 
from ordinary causes of derangement acting upon a body al- 
ready in a state of irritation and fever, and therefore peculiarly 
susceptible to their malign influence. 

These complications are for the most part stomatitis, repeated 
vomiting and diarrhea, gastritis, cough from pulmonary catarrh, 
otitis, various forms of skin disease, and certain disorders of 
the nervous system, such as squinting, tonic contractions of 
muscles, convulsions, etc. 

Some children at this time are remarkably subject to colds, 
and pulmonary catarrh is a common complication of teething, 



PREMATURE DEC A 2' OF TEETH. 225 

and when present should never be neglected, for the reason 
that it may easily lead to a severe bronchitis or broncho-pneu- 
monia. If the teeth are cut in rapid succession, a looseness of 
the bowels is apt to prevail to a greater or less degree during 
the whole period of dentition. If the looseness remains con- 
fined within moderate bounds, it may do no harm ; but on the 
contrary have a salutary effect in relieving the irritation and 
tension of the nervous system. It should not, however, be 
allowed to transcend certain bounds, especially in the summer 
time, for the reason that a simple and innocent diarrhea may 
be quickly changed into the inflammatory form from some 
indiscretion in eating or sudden atmospheric changes, and speed- 
ily get beyond control. 

The ordinary diarrhea of teething consists of green or yellow 
matter with small lumps of undigested curd. The latter char- 
acteristic is obviously due to a fault of digestion, and if attrib- 
uted solely to the teeth might be allowed to go on without 
treatment, which would be decidedly improper. Food, such 
as milk, that may have been perfectly well digested under other 
circumstances, may be entirely indigestible now, and if so, 
should be changed to cream or raw-meat juice or to some other 
bland and unirritating food, and remedies should be adminis- 
tered to relieve the gastric irritability before milk can safely be 
resumed again. 

Premature Decay of Teeth. — There is a marked differ- 
ence in children as regards the tendency to decay in the decid- 
uous teeth. As a rule, more or less of them decay before they 
fall out, and before the permanent set are ready to replace 
them. In such cases it is very bad practice to have them 
extracted, for the reason that the pressure of the tooth in its 
socket is necessary to preserve the contour of the jaw-bone and 
prevent the permanent tooth behind it from coming in crooked. 

When the milk teeth are extracted prematurely, the perma- 
nent set are almost certain to present an irregular and unsightly 
outline. This can easily be prevented by killing the nerve of 
the milk tooth with creosote or otherwise, and filling the cavity 
with cement or some inexpensive material that will stop the 
tooth from aching and preserve its usefulness, until its fellow 
of the permanent set is ready to take its place. 

As soon as one of these teeth shows signs of decay, the child 
should be taken to a dental surgeon at once. If delayed, the 
tooth will soon begin to ache and the child will refuse to use 
it for purposes of mastication. As a result the food will be 
" bolted," indigestion will follow, and immense mischief may 
result. 

D. C— 15 



226 THE DISEASES OF CHILDREN. 

The Permanent Teeth. — The second or permanent set of 
teeth numbers thirty-two, and erupt in the following order, those 
of the lower jaw preceding those of the upper : 

Sixth year, first molars. 
Seventh year, central incisors. 
Eighth year, lateral incisors. 
Tenth year, first bicuspids. 
Eleventh year, second bicuspids. 
Twelfth to thirteenth year, canines. 
Thirteenth to fifteenth year, second molars. 
Seventeenth to twenty-first year, wisdom teeth. 

It will be noticed that the permanent teeth are as many 
years in erupting as the milk teeth are months, which fact 
explains in a measure, at least, why the system is so much 
more liable to be disordered in the latter case than in the 
former. 

Treatment of Dentition.— In the majority of cases the 
troubles which are incidental to teething are not attended with 
danger, but are trifling in their nature and transient in their ef- 
fects. Some infants, however, suffer torture with every new 
tooth and require relief quite as much as if the disturbance was 
more serious. Fortunately for these sufferers, there are many 
remedies of great value, which, properly given, may not only 
ameliorate present pain, but obviate serious complications. 
When simple diarrhea is present, it does not, as already inti- 
mated, require treatment so long as it remains simple and not 
profuse enough to cause exhaustion. Should it pass these 
bounds, however, such remedies as are mentioned under the 
head of Diarrhea may be given, the particular remedy being 
chosen with regard to the special indications of the case. In 
case the stomach is irritable from reflex sympathy, it may be 
necessary with bottle-fed infants, to change the food tempo- 
rarily to one more bland and easily digested. When cow's 
milk has been used, cream may be advantageously substituted 
for a few days, or some one of the more easily digested baby 
foods, although it be less nutritious and tissue-making than 
that previously given. After a day or two the regular food 
should be resumed. Barley water or the bread jelly mentioned 
on page 56 may answer temporarily. When the teeth are slow 
in making their appearance, or when they decay soon after 
eruption, calcarea carb. should be given in the third decimal 
trituration, a one-grain powder three or four times daily. In 
case the teeth are much delayed and the gums remain a long 
time swollen, white and painful, calc. phos. is the remedy. It 



TREA TMEN T OF DEN TI TI ON. 227 

is all the more indicated if the infant sweats much about the 
head whenever it falls asleep. 

When there is a hacking cough (symptomatic or reflex), nux 
vomica ; this remedy is also indicated in constipation. 

With violent thirst, heat, fever and restlessness, aconite. 

Belladonna is indicated by starting in sleep, face flushed, 
jerking or twitching of muscles, as if convulsions were im- 
pending. 

When there is sleeplessness, much agitation, now crying and 
then gay, coffea. If convulsions have already developed, gel- 
semium or cuprum, according to their special indications, 
should be given. (See passiflora.) 

The symptoms calling for ignatia are trembling all over ; 
piercing screams ; convulsive jerkings of single parts ; stools 
attended with tenesmus and prolapse of the anus; child cries 
and sobs, and the latter continues after the crying subsides. 
Mercurius Sol. — copious salivation, and sometimes little blis- 
ters are seen on the tongue, gums and cheeks ; quite large ulcers 
are sometimes seen on the protruding gum ; sleeplessness ; 
stools green, slimy and accompanied with tenesmus. Silicia — 
in scrofulous children who easily take cold, stools difficult, dry 
and hard ; the stool often recedes before its passage is effected ; 
profuse sour-smelling perspiration covering entire body, or af- 
fecting the feet more particularly ; fever toward evening, and 
lasting into the night. Hellebens nig. — when brain symptoms 
predominate, and a hydrocephaloid condition exists or seems 
impending ; child has spells of frenzy, very excitable ; com- 
plains of falling ; sleeps badly ; stools white and jelly-like. But 
the remedy of all remedies, and the one most often called for 
during the teething period, is chamomilla. This remedy is to 
infants and children what Pulsatilla is to w^omen ; a veritable 
vade inecum. Its special indications are great restlessness, start- 
ing and jumping in sleep ; when awake it wants to be carried 
all the time ; one cheek red, the other pale ; great thirst ; gums 
red and tender ; dry, hacking cough ; very thirsty, likes to hold 
its mouth a long time in cold water while drinking ; stools 
grass-green, or slimy with mucus. The symptoms are very 
similar to coffea and belladonna, but it has a different colored 
stool, and the symptoms are more manifestly of local origin. 

At the risk of seeming to be dogmatic, I would say that 
aconite^ belladonna, cJiamomilla and gelscinhivi form a quartette 
of remedies that will meet nearly every indication arising in 
the course of teething, where remedies are called for. There is 
another remedy with which I have recently become acquainted, 
and which seems to meet the erethism present in these cases 
better than any other remedy. It is passiflora, or the passion- 



228 THE DISEASES OF CHILDREN. 

flower. No proving has yet been made of it, that we are aware 
of, and it is generally used in the form of the tincture or fluid 
extract. Of the tincture, ten to fifteen drops may be given 
to a child under six months of age, and to an older child twice 
this quantity. It is used somewhat empirically by the eclectic 
school for convulsions, nervousness, wakefulness, and tetanoid 
conditions. In three cases of eclampsia in which I have used it, 
it gave prompt relief ; diminished the severity and frequency 
of the spasms, and seemed to act promptly and continuously. 
In one case where an infant a year old had been having spasms 
at frequent intervals for twenty-four hours, only one convulsion 
occurred after this remedy was given. It should be given in a 
little sweetened water. In all cases where the physician is 
called to attend a young infant or child, the state of the gums 
should be ascertained by personal inspection. In many in- 
stances the gums will be found swollen, hot and tender, and the 
promptest relief will be afforded by incising them. 

The Gum Lancet in Difficult Dentition. — It seems 
passing strange that nearly all recent authors on the diseases of 
children speak slightingly or deprecatingly of the lancing of 
gums of teething children, while all recent authors on dental 
surgery are outspokenly in favor of it. Such eminent authori- 
ties as Rilliet and Barthez utterly discountenance it, while one 
of the latest and highest authorities in this country makes the 
statement that the gum lancet "is used more by the ignorant 
practitioner who is deficient in the ability to diagnosticate ob- 
scure diseases than by an intelligent man who can discover 
more clearly the true pathological state." Such a statement as 
this, coming from such high authority, would be paralyzing to 
the young practitioner were it not a well-known fact that many 
children die of convulsions, or drift into a hopeless eclampsia, 
when the most rigid search by the most skillful physician can 
reveal no pathological state except tender and swollen gums 
overlying an impacted tooth, that may be released and all pain 
and reflex phenomena relieved immediately by the use of the 
gum lancet. 

A case recently sent to me for diagnosis and advice by my 
friend. Dr. J. D. Burns, of Grundy Center, Iowa, will illustrate 
what has just been said. The child was a girl eighteen months 
old, well developed and the picture of rosy health. The doctor 
may tell his own story. I quote from the letter which accom- 
panied the child. '' For nearly a year she has been troubled 
with a nervous affection which does not yield to treatment. 
The trouble is spasmodic in its nature and epileptiform in 
type. The peculiarity is that she always cries and holds her 



G UM LA NCE T IN DIFFIC UL T DEN TI TION. 229 

breath at the beginning or onset, the spasm being preceded by 
more or less jerking of the tendons, when a general spasm en- 
sues, first tonic, then clonic, lasting from a few minutes to a 
half, and the mother says a whole, hour, which is succeeded by 
great exhaustion, drowsiness or sleep. The spasms recur at 
indefinite periods of a day or two or a week. I have used sev- 
eral remedies with no apparent benefit." 

I learned from the parents who brought the child and the let- 
ter at the same time that the spasms, as they undoubtedly were, 
dated back some months, at which time the child was eight 
months old and cutting its first teeth. Up to this time she had 
been perfectly well, a good feeder, a good sleeper and regular 
in all her functions. When brought to me she had eight teeth, 
but all of them had come through the gums with difficulty. 
Shortly before the successive appearance of each tooth the 
" spells," as the mother called them, were more frequent. 
Twice it happened — being recalled to mind during the examina- 
tion — that they occurred at the dinner table while the child 
was sucking the handle of a teaspoon or table knife. It was 
further recalled that any sudden shutting of the jaws together, 
as in a fall on the floor, was followed by a spasm. An inspec- 
tion of the mouth showed the gums over the first molars to be 
hard, tense and swollen. On using the gum lancet an unusual 
amount of fibrous tissue was encountered, which cut like gristle. 
A crucial incision was made deep down to the crown of the 
tooth, but only a drop or two of blood exuded as a result ; the 
child, however, immediately began to cry and went into a spasm 
which lasted about five minutes. 

Both before and after lancing the gums I made a most ex- 
haustive physical examination of the child, to see if I could find 
any " pathological state," other than teething, to account for 
the pathological condition, but with negative results. The 
case was evidently one of eclampsia, with an epileptiform ten- 
dency. My prognosis was a guarded one. The eclampsia had 
been of so long standing — nearly a year — that the convulsive 
habit had become established. The result will probably be death 
or a confirmed epilepsy. But if the strictest care be taken to re- 
lieve the nervous system from undue irritation by frequent and 
deep scarifications of the gums, and a proper attention be given 
to diet while the teething process is going on, possibly better 
results may be obtained. 

Some three months after first seeing this case I received from 
Dr. Burns the following letter, in answer to my inquiry as to 
how the case was progressing: 

Dear Doctor — Yours of the 20th inst. inquiring about the Wilson child 
received today. In answer ^vould say, the child is somewhat better; the 



230 THE DISEASES OF CHILDREN. 

spasms are less frequent and less severe, but she still has spasms. I have 
cut her gums five or six times, every time down to the teeth, but they erupt 
slowly, and the gums are as tough as cartilage, and grate under the knife; 
have continued the passiflora in from 5 to 15 drops every two to six hours. 
I have used other remedies, rnz.: santonin 3X, nux vom. 3X, ignatia 3X; 
changed the food, dilated rectum and urethra, used a 4-per-cent. sol. of co- 
caine on the gums, etc. I am satisfied the great source of irritation is the 
teeth and digestive system. I have never seen such tough gums, and tender, 
too. Every time they are freely lanced she is better. 

If this were an isolated case, the argument in favor of lancing 
the gums would have but a flimsy foundation. But such a 
case as is here described is not isolated. Every physician of 
extensive practice must have met many similar ones. I recall 
many cases myself of extreme restlessness, fever, diarrhea, ina- 
bility to nurse, with jumping and starting in sleep, all of which 
symptoms were promptly relieved, without medicines, by incis- 
ing the swollen gums. 

The symptoms just referred to may precede the eruption of 
a tooth by several weeks — when, as old nurses say, the teeth 
are " breeding" in the gums. It should be understood that the 
object of cutting the gum is not merely to hasten the cutting 
of a tooth. There is generally no necessity for haste in this 
matter, unless there be obvious constitutional disturbance 
resulting from delay. This disturbance and any reflex phe- 
nomena secondary to it do not arise from pressure of the tooth 
upward against the gum, but downward against the dental 
nerve at the tooth root. As the tooth progresses forward the 
root of the tooth progresses downward. When dentition 
advances normally the alveolar processes of the jaw, which 
have hitherto confined the tooth closely, are absorbed and 
cease to hinder its advancement and nothing prevents the rapid 
and painless eruption of the tooth, but the covering of the gum. 
When this covering is thick, tense and inflamed, the eruption of 
the tooth is delayed and an incision of the gum affords imme- 
diate relief. When absorption of the alveolar processes does 
not take place synchronously with the other phases of tooth 
evolution ; when, in other words, the obstruction is in the jaw 
rather than in its coverings, lancing the gum is obviously of 
little or no avail. It is during the " breeding" stage, or later 
on, when the advancement of the tooth is hindered by the un- 
due thickness or undue hardness of the soft covering, that lanc- 
ing is most beneficial. In these cases we find the gum promi- 
nent and in a state of tension over the advancing tooth. Under 
these conditions the gum should be divided down to the surface 
of the tooth, not at a point only, but across the whole breadth 
or length of the crown ; in fact, the imprisoned organ should 
be set free. 



GUM LANCET IN DIFFICULT DENTITION. 231 

The objections urged against lancing the gums are so illog- 
ical or so trifling as to be scarcely worthy of serious consider- 
ation, and to need only a few words of refutation. The possi- 
bility of serious hemorrhage is very remote ; so rarely is it 
encountered that I have never seen it, but even if it were more 
frequent the same argument would apply to every surgical 
operation and to all medication. No procedure should be 
abandoned or forbidden, nor is it contra-indicated, because of an 
occasional fatality, the result of an idiosyncrasy or of exceptional 
and unexpected complication. As a rule there is no such dan- 
ger, and the operation is safe and practically painless. That the 
operation sometimes demands frequent repetition is no more 
of an objection than appertains to any medication which fails 
to afford permanent relief from a single dose. There is posi- 
tively no danger of injury to the developing tooth or its 
enamel, except through the grossest ignorance of the anatomy 
of the mouth or through the most culpable carelessness. 
Probably the most commonly urged objection is that unless the 
tooth is erupted before there is time for the wound to heal a 
cicatricial tissue is formed, which offers increased resistance. 
This argument is in direct contravention of recognized facts as 
to the reparative process. Cicatricial tissue is always and 
everywhere of a lower degree of organization than the original 
structure, and consequently easier of absorption. The tendency 
of scar tissue to break down by reason of its lower vitality is a 
matter of common observation, and, except in the case of gum- 
lancing, is not disputed by any medical authority. Gum tissue 
offers no exception to the general rule. 

While the operation of lancing the gum is a trifling one, the 
manner in which it is performed has much to do wdth its success 
or failure. As has been already stated, the object is not merely 
or chiefly to cause a flow of blood, but to remove tension. The 
cuts should, therefore, be made with special reference to the 
form of the erupting tooth, and should be sufficiently deep to 
reach the presenting surface and to extend fully up to and a 
little beyond its boundaries, so as to insure its entire liberation. 
It is well to direct the point of the lance toward the lips, 
instead of toward the lingual or palatal surface of the oral teeth, 
as there is thus less liability to injure the crypts of the perma- 
nent teeth, if from any cause the cuts should be made deeper 
than intended. Partial eruption of a tooth is generally accepted 
as a solution of the problem, the slightest presentation being 
considered as definitely deciding against the necessity of lanc- 
ing. This is generally true in the case of the incisors — far from 
true of the cuspids and molars. The cone shape of the cuspids 
insures a persistence of the trouble, from pressure of the 



232 THE DISEASES OF CHILDREN. 

inclosing ring of gum, until fully erupted. A complete severance 
of this fibrous ring on the anterior and posterior, as well as 
lateral, surface is indicated, and is even more necessary than 
before the partial eruption of the tooth. All the cusps of a 
molar may have erupted, and yet strong bands of fibrous integu- 
ment maintain a resistance as decided as before their appear- 
ance. In this case either the boundaries of the tooth should 
be traced with the lancet and all such bands severed around its 
outlines, or a crucial incision should be made so as to insure 
perfect release from pressure. 

Whenever lancing of the gums is deemed necessary, it should 
be done in the spirit of the adage, " What is worth doing at all 
is worth doing well." The modus operandi in carrying out 
this aphorism is so well described by Dr. James W. White, in 
the "American System of Dentistry," that I beg leave, for the 
benefit of young practitioners, to give it in his own words : 

*' The operator should be seated directly in front of his assist- 
ant, the knees of the two parties corresponding in height. 
Some direct the child to be held cross-wise on the lap of the 
assistant ; others prefer to be behind the head of the child ta 
operate on the left side, and in front to operate on the right 
side of either jaw. Others take the head on their knees when 
operating on the upper jaw, and place the head on the knees 
of the assistant when operating on the lower jaw." (In either 
position it will be observed that the assistant has complete con- 
trol of the hands of the child.) " The left hand of the operator 
should separate the jaws and protect the tongue and lips of the 
child in such a manner that any unexpected movement may 
result in injury to his own fingers rather than to the child. In 
the case of a child disposed to bite, the insertion of a small 
cork between the jaws will be of service. This should be 
guarded from falling into the throat by a piece of string or 
tape, which should be held in the desired position by the as- 
sistant." It is rarely necessary to use this expedient, or to use 
any force after a child has once submitted to the operation, for 
the pain is so trifling, and the relief from suffering so great and 
immediate, that it is desired rather than feared. 

The instrument employed should always be a gum lancet, 
used for this purpose and for no other. An ordinary bistoury 
used for miscellaneous purposes is never permissible. 

We have sometimes derived benefit from having the gums 
rubbed occasionally with a two to four per cent, solution of co- 
caine ; chamomilla and witch hazel are also palliative when 
rubbed on the gums, and may be used when lancing the gums 
is contra-indicated or is objected to. 



PART IV. 

DIATHETIC DISEASES. 



CHAPTER I. 
GENERAL CONSIDERATIONS. 

The diseases which we are about to consider, are variously 
designated by authors as the diathetic, cachectic or the constitu- 
tional maladies. They are very widely distributed among the 
human family, but are much more common in civilized coun- 
tries than in those which are semi-civilized, or barbarous. They 
are far more common, also, among the poor and squalid, than 
among the wealthy and well-to-do. With the possible excep- 
tion of tuberculosis, they are not contagious nor infectious. 
The question of their hereditary origin is one about which 
authorities differ, and about which volumes might be written 
without reaching a definite conclusion. Even if it were other- 
wise, the question could have no practical bearing, and we 
therefore leave it to those who have a special taste for polemi- 
cal discussions. Either of them may be congenital, but more 
often they do not exhibit their symptoms until some time after 
birth. They all incline to be chronic rather than acute ; and 
may remain in a latent condition for a lifetime without appar- 
ently abbreviating life itself. They are all characterized by 
such distinct and positive symptoms as not to be easily mis- 
taken one for the other. 

One of the peculiarities of this group of diseases is that each 
and all, either primarily or secondarily, involve the nutritive 
sphere of activity, and work their principal ravages in the elab- 
orative organs of the body. 

In tuberculosis and scrofula, the great lymphatic system is 
principally involved. The importance of this system has, we 
think, been underestimated by physiologists and neglected by 
pathologists. Indeed, the whole glandular apparatus, whose 

(233) 



234 THE DISEASES OF CHILDREN. 

ramifications are co-extensive with vitality, is but imperfectly 
understood. The real functions of the liver and spleen are to- 
day involved in doubt and speculation. This much seems prob- 
able, that the lymphatics constitute the great absorbent system, 
whose ofifice is to take care of waste products, and at the same 
time furnish, in part, at least, the necessary material for the re- 
newal of life. It is the connecting link between the alimentary 
canal and the blood current, on the one hand, and an accessory 
venous system on the other. In early life the lymphatic system is 
very active, much more so than in maturity, and any derangement 
along the course of its innumerable channels is sure to be attended 
by some sort of mischief. The lymphatics may be atrophied con- 
genitally, or by acquisition, and in either case we have as a result, 
a lack of growth and feeble powers of vitality, from a starved con- 
dition of nerve centers. On the other hand, and in contrast with 
the anemia which attends atrophy, we may have an hypertrophied 
condition of the lymphatic glands, in which case we have an 
excess of white corpuscles in the blood, a condition known as 
leucemia or leucocythemia. 

This hypertrophy of lymphatic glands causes the develop- 
ment of small, painless, compressible tumors, which are espe- 
cially noticeable in the lumbar, mesenteric, epigastric and bron- 
chial structures. 

Microscopical examination in hypertrophy of this simple 
variety, shows only the normal elements of glands, and the to- 
tal absence of any pathological new formation. In this respect 
it differs materially from the hypertrophy accompanied by 
inflammation, which we find in scrofula, and there is no tend- 
ency in simple hypertrophy to suppuration. Its prominent 
symptom is, in addition to the swellings above mentioned, a 
sickly pallor of countenance, a waxy hue of the skin, and a 
generally debilitated state of the system. The causes most 
active in the production of this condition are unsuitable food 
and bad hygienic surroundings — conditions which medicines 
are powerless to overcome. 



CHAPTER II. 

RACHITIS (rickets). 

Definition ; Course. — Rachitis is essentially a disease of the 
bones or of the bone-producing tissues, and is a common re- 
sult of faulty diet and of anti-hygienic conditions. It is 
preeminently a disease of infancy, having but little in common 
with that disease of mature life known as osteo-malacia. 

For purposes of clinical study the disease may be divided 
into three stages : first, the stage of invasion, which is essentially 
one of malnutrition ; second, a stage of deformity, during which 
there is more or less distortion of some of the bones of the 
skeleton — the most noticeable changes being usually in the 
bones of the head, the ribs and the radial bones ; the third 
stage is one of reconstruction or repair, during which the de- 
formities resulting from the disease are in most cases so nearly 
overcome that in mature life but little if any trace of them is 
left except in stunted growth, which neither nature nor art can 
rectify. 

Frequency. — The world over, rickets is known as the English 
disease ; but just why is hard to explain, for statistics do not 
show any great preponderance of it in the British Isles over 
other countries where the population is equally compact, and 
where the communities are similarly domiciled. The fact is, 
the disease is prevalent in all countries and among all nations, 
and if the health records were equally well kept, there would 
probably be found little difference in prevalency in one country 
over another. But statistics, however reliable they may be in 
a general way, are utterly valueless in estimating the relative 
prevalency of rachitis, for the reason that its inception is insidi- 
ous, and its progress is often arrested before medical treatment 
is invoked. Many cases of rachitis do not go beyond the incip- 
ient stage, when fortuitous circumstances, such as change of 
diet or air, produce a spontaneous arrest of the disease, and 
not even the family physician is made aware of the fact that a 
rachitic condition has been menacing. 

Such cases as these never reach the record books of hospital 
or dispensary. Furthermore, the symptoms of rachitis are 

(235) 



236 THE DISEASES OF CHILDREN. 

often complicated by those of other disorders, of an acute na- 
ture, such as bronchitis and affections of the stomach and bow- 
els, which overshadow and obscure the fundamental trouble 
and cause it to be overlooked. In a somewhat loose and un- 
scientific, but still in a practical and emphatic way, one can 
judge something of the prevalence of pronounced cases of the 
disease by noticing the number of undersized and bow-legged 
males, and of females with illy-formed shoulders and backs, in 
any community in which he may happen to be, for the major- 
ity of these distorted forms are occasioned by early rickets. It 
is quite true that other causes besides rickets arrest growth 
and prevent the bodies of children from reaching an ideal form ; 
but no other disease is so commonly responsible for malforma- 
tions and a lack of symmetrical development. Jenner says : 
" Rickets is the most common, the most important, and in its 
effects the most fatal of diseases which extensively affect chil- 
dren." Hassowitz says that in Vienna the number of cases 
among all classes, rarely falls below eighty per cent. Dr. 
Thomas Barlow says, " If the question of craniotabes be left 
out, and attention be carefully directed to the junction-area 
of the fifth and sixth ribs, there will be no difficulty in finding 
at least fifty per cent, of examples of distinctive rickets among 
children under two years attending the out-patients' depart- 
ments of London and Manchester." These figures are mani- 
festly merely estimates, but may be taken for what they are 
worth. They point out the fact very plainly that rachitis is 
very much more frequently met with than has been generally 
supposed. 

Causes. — There is the greatest diversity of opinion among 
pathologists as to the real cause of rickets. Vogel, Parrot, and 
many others believe that constitutional syphilis in the parent 
may cause rickets in the children. Others of equal eminence 
deny this in toto. 

However we may regard the disease from a controversial 
standpoint ; how many soever factors may be considered as 
entering into the etiology of a given case, all authorities are 
agreed upon one point, viz., that the one factor that enters 
prominently into every case is the factor of defective food. It 
matters not whether the rachitic child has been nursed at the 
breast or has been bottle-fed, the one indictment that cannot 
be quashed, the one fact that cannot be denied, is the insuffi- 
ciency or inefficiency of the food supply. In the beginning of 
every case of rickets, there is somewhere a fault that amounts 
to a failure, in the matter of alimentation. The nourishment 
does not nourish. Some essential element necessary to the 
economy is either absent or is presented in a form which is 



RACHITIS. 237 

ineffective. With a ravenous appetite there is lack of normal 
growth. With abundance of aliment there is perverted nutri- 
tion. Abundance does not satisfy ; there is starvation in the 
midst of plenty. 

When breast-fed children develop the rachitic habit, it is 
usually not until after they are eight or ten months old, at 
which time it is well known the milk of nursing women is apt 
to deteriorate. This fact is a very significant one. All statis- 
tics relating to the subject go to show that there is a direct 
and proportionate relationship between prolonged lactation 
and rachitis. Women who nurse their children into the second 
year, either because breast-milk is cheaper than other food, or 
because of a fancied immunity from pregnancy which nursing 
is supposed to afford, or for other reasons, should know that 
their children are very apt to be rachitic. Then again, there 
are women whose milk is never good, no matter how abundant 
it is, nor how young and seemingly healthy are the women them- 
selves. A woman who has once nursed a rachitic child should 
never attempt to nurse another one. But with all nursing 
women there comes a time when the milk loses its nutritive 
qualities and becomes as an aliment but little better than 
water. W^hen such is the case, if nursing is persisted in, the 
infant is in great danger of developing rickets. I know of no 
reliable means of ascertaining the time when, in a given case, 
the milk begins to deteriorate by any chemical, mechanical or 
microscopical test. The time unquestionably varies with dif- 
ferent women, and with the same woman at different times ; 
but I am satisfied from personal observations, that, with Amer- 
ican women, especially with those living in large cities, this 
time is on the average less than twelve months. Indeed, in 
some cases it may be as early as the fifth or sixth month. The 
occurrence of pregnancy or the return of menstruation hastens 
it. To nurse a child beyond this time, whether it occurs sooner 
or later, is always perilous. But the nursling is not the one 
most commonly menaced by rachitis. As we have endeavored 
to show in the chapter on Foods and Feeding, the bottle-fed 
infant is the one who is most heavily handicapped in the race 
of life ; and it is the artificially fed children who most readily 
fall victims to this disease. But it ought not to be so. The 
principles of bottle feeding are reasonably clear, and the variety 
of wholesome foods is ample for ordinary needs, if only 
intelligently selected. Many children drift into a rachitic 
state very soon after being weaned, because of a mistaken 
idea that a healthy infant can go directly from the nurse's 
breast to the general table and there be fed on whatever its 
fancy dictates. 



238 THE DISEASES OF CHILDREN. 

Histological. — Malnutrition is the principal characteristic of 
the initial stage of rickets. Until quite recently it was held 
that certain deleterious elements, admitted into the system with 
the food, or generated within the system from the food, stood 
in their relation to rickets as cause and effect. Experiments 
made on the lower animals, especially on dogs and rabbits, show 
that rickets can be produced in them at pleasure, by giving 
them lactic acid in small but frequently repeated doses while 
they are yet young. It was thought, therefore, that the gen- 
eration of lactic acid within the system from the use of starchy 
foods was the prime factor in the causation of rickets. This 
acid, it is well known, is commonly produced in large quantities 
in young children as a result of improper feeding, and thus a 
satisfactory solution of this vexed question seemed easily 
reached. But the clinical fact has been elicited that children 
develop a rachitic condition, in whose blood there is certainly 
no excess of lactic acid. On this point. Dr. J. Lewis Smith 
says : " Rachitis sometimes occurs in infants who present no 
history of indigestion or of intestinal catarrh, and in whom there 
is no ground for the belief that lactic acid, or any other acid, is 
produced in undue or injurious quantity. In a considerable 
proportion of such cases, inquiry elicits the fact of anti-hygienic 
conditions, but there is no evidence of imperfect digestion or 
of gastro-intestinal catarrh, such as produces lactic acid. In 
the cases occurring in the New York Infant Asylum, alluded to 
above, some of the children had manifest gastro-intestinal de- 
rangement, but others, who were wet-nursed, gave no evidence 
of faulty digestion, though the nutriment which they received, 
was probably insufificient ; for, as already stated, by providing a 
more liberal diet, by allowing, among other articles, the juice of 
meat, rachitis became much less frequent and is seldom observed 
at present among the infants of that institution, unless in a very 
mild form." 

The experiments of Heitzmann, Virchow and others show 
that one of the factors in the production of rachitis, is a defi- 
ciency of calcareous salts in the food supply; but it is doubtful 
whether an excess of lactic acid or the deficiency of earthy salts 
is sufficient alone to produce the disease, or whether both con- 
ditions combined are present in all cases. 

On the contrary, there is good reason to believe that the 
causes are not uniform in all cases, but that varying conditions 
operate in different patients to produce the same pathological 
result. 

This pathological result is a disproportion between the organic 
matter and the earthy salts in the various bones which make 
up the framework of the organism. In healthy bones the inor- 



RACHITIS. 230 

ganic elements predominate over the organic in the proportion 
of two to one ; but in rickets the proportion is reversed, the 
organic matter being greatly in excess. There is a great diver- 
sity of opinion as to just how the disproportion of elements 
originates. Some maintain that the earthy salts are not elab- 
orated into bone, the process of ossification being arrested in 
its course ; while others claim that, by reason of the excess of 
lactic acid present, the bony matter is absorbed or dissolved 
after being wholly or partially elaborated, leaving the organic 
matter but little altered. 

If a long bone be macerated in acid for a time suf^ciently 
long to dissolve out the inorganic matter, it becomes possible 
to bend and twist it at pleasure. Such a bone is typical of one 
affected by the rachitic disease. About the ends of the long 
bones we find a proliferation of the cartilage cells, and in conse- 
quence a growth of bone which is larger and coarser than the 
same in health. A rachitic bone when dried is so openly porous 
that one can readily breathe through it as through a sponge. 
In a rachitic bone the ends of the shafts are ossified by cells 
not only larger, but more fragile than normal, while along the 
center of these long bones ossification is so slow and imperfect 
that it readily bends when subjected to any weight or pressure. 
In mild cases of rickets only a few bones may be affected ; but in 
severe cases every bone in the skeleton may be more or less 
altered in its histological elements. The tendency of the disease 
is always to shorten the long bones, such as those of the limbs, 
and to soften the flat bones, such as those of the skull. This 
accounts for the square box shape of the head, and the stunt- 
ing of the figure of a rachitic child. The retarded ossification 
of the bones in rachitis is more marked in some bones than in 
others. It is especially noticeable in those of the skull. The 
sutures remain open for a long time and the fontanels do not 
close until long after they should. In a healthy infant the 
anterior fontanel should be closed between the fifteenth and 
twentieth months, but in the rachitic it may remain open for 
two or three years. 

In should be borne in mind that in the normal state of affairs 
the brain increases in size during the first six or seven months, 
more rapidly than does the development of bone, so that up to 
this age the anterior fontanel is larger than at birth ; but after 
the ninth month it becomes progressively smaller, until it is 
finally closed at the age above mentioned. 

The other bones which exhibit most strikingly the rachitic 
change, are the ribs and the radius — the sternal end of the ribs 
and the lower end of the radius. 

It is seldom that these bones do not give evidence of the 



240 THE DISEASES OF CHILDREN. 

disease, if it be present, and in greater degree than other bones. 
They are the first to be affected to an extent that is appre- 
ciable to the observer. 

Craniotabes, first described by Elsasser in 1843, has till lately 
always been held to be a sign of rickets. M. Parrot and others 
have called this doctrine in question, and considerthecomplaint 
a sign, not of rickets, but of congenital syphilis. Craniotabes, 
or wasting of the skull, is a condition of softening of the bones, 
particularly of the postero-parietal region, by which, under mod- 
erate pressure from the finger, the bone caves inward with a 
crackle like that of stiff parchment. It is of two kinds : in very 
young infants the bones of the skull will yield under pressure, 
and sometimes crackle, but this is not a diseased condition. 
The true disease generally exists in localized patches. It is 
said to occur in thirty to forty per cent, of all cases of rickets, 
and is found to perfection from six months after birth onwards. 
It is an open question how far this condition is due to uncom- 
plicated rickets, and how far to syphilis ; but it is a remarkable 
fact that, since the question was mooted, some very weighty 
evidence has been produced in favor of its association more 
with syphilis than wdth rickets. Dr. Thomas Barlow and Dr. 
Lees collected 100 cases of craniotabes, and have published 
the results of a most careful inquiry upon its relationship both 
to syphilis and rickets. From it they conclude that forty-seven 
per cent, of the total are almost certainly syphilitic ; and t'o 
this may be added the observation of Dr. Baxter, that of the 
twenty-three per cent, of craniotabes in rachitic children, 
seventy-five percent, were syphilitic. 

The skull of a child affected with craniotabes shows shallow 
depressions at the diseased parts, smoothly bevelled off into the 
surrounding bone. The depressed areas may be so numerous 
as to give the inner table a somewhat trabeculated appearance. 
The thin layer of bone which covers in the depression is that 
which gives the crackle as it bends inwards on pressure. In 
some cases the thinning is more general, involving, perhaps, the 
entire occipital bone ; in others, the local thinning is consider- 
able, and may go on to the formation of a number of mem- 
branous opercula. In other cases, again — and the real nature of 
such is still open to question — there is much tendency, not only 
to thinning and softening, but to the formation of new bone, 
in most cases leading to the production of a velvet pile-like 
layer of osteophyte over the surface of the calvaria between the 
sutures and the centers of ossification. In this way the sutures 
come to form furrows, and the shape of a hot cross-bun is pro- 
duced — the natiform skull — and sometimes the bone formation 
may be so active that the skull may reach a thickness of half 



RACHITIS. 241 

an inch or more. The new bone is very soft in all these cases, 
can be cut with a knife, and is of a peculiar claret color, from 
the amount of blood it contains. Many consider this condition 
of the skull to be a sign of congenital syphilis. It is certainly 
frequently found in syphilitic infants — in infants in whom other 
evidences of rickets, though not absent, are yet of the slightest. 
Nevertheless, I do not think that one can altogether exclude 
rickets from a share in its production. 

Other signs of rickets are found in the epiphyseal extremities 
of the long bones, and in the ribs. In these the ossifying layer 
of cartilage at the junction of the epiphysis with the shaft, or 
in the case of the ribs at the junction of the costal cartilage 
with the bone, becomes swollen — sometimes enormously so — 
and thus is produced a characteristic swelling of wrists and 
ankles, and a beading of the ribs. These symptoms, although 
present in most cases, are by no means remarkable in many. A 
child may be very rachitic as regards its head and dentition, 
and perhaps show a distorted thorax, enlargement of the spleen, 
and even curvature of its bones, while yet there is but little 
enlargement either of the ends of the ribs or of radius or tibia. 

The bones are soft in rickets, and thus come sundry charac- 
teristic distortions of spine, thorax, pelvis, and long bones. In 
the thorax a double curve is assumed, the ribs fall in at their 
junction with the costal cartilages, and a vertical depression of 
considerable extent is produced in such parts of the thorax as 
are not supported by the solid viscera. The abdominal viscera 
prevent the falling in of the lower part of the chest ; the lat- 
eral parts of the upper segment fall in considerably ; whilst the 
sternum becomes rounded and prominent, and the antero-pos- 
terior diameter of the chest becomes the dominant one. Some 
have distinguished between this, the chest of the rickety child, 
and the distortion due to other causes, such as atelectasis, or 
non-expansion of the lung. In the latter the ribs yield gener- 
ally from their angles forwards, and the transverse section of the 
chest becomes of a peg-top or angular shape, from the sternum 
becoming carinated. On a priori grounds it may be argued 
that the softened bone curves, not only at the epiphyses, but 
also generally in its length ; there is ample evidence that it 
actually does so ; and there seems little reason why the ribs 
should not thus yield. The worse the rachitic condition, so 
much the more yielding will there be, and the lateral grooves 
will then be pronounced. In the less severe cases the recession 
of the chest-wall will be less, and che chest will approach the 
angular type. Moreover, by no means is it certain that this 
shape does not represent a partial obliteration of the more 
marked distortions. It is much more common in children of 
D. C— 16 



242 THE DISEASES OF CHILDREN. 

six, eight, or ten years. The grooved chest is the common 
type of infancy. It is certain that, as the child grows and the 
bones harden, the deeper dip of the ribs at the costo-chondral 
articulations gradually expands again ; while the antero-pos- 
terior expansion of the lung has become in a measure perma- 
nent, and tends to perpetuate the prominence of the sternum. 
In the same manner occur those distortions of the pelvis, which 
are so commonly noticed in the victims of rickets. 

That of mollities ossium is beaked, or Y-shaped ; of rickets, 
contracted in its antero-posterior capacity by the sacral prom- 
ontory being unduly prominent. But in extreme cases of 
rickets, when the body weight has been unduly thrown upon 
the pelvis, the acetabula may be forced backwards into the 
pelvis, and a beak be produced by the symphysis and pubic 
bones. The fibula and tibia bow outwards and forwards ; 
the radius and ulna curve outwards ; and in extreme cases the 
natural curves of the clavicles become much exaggerated. 
These conditions go with (sometimes they may be replaced by) 
an unnatural relaxation of the ligaments, particularly at the 
knees, and thus cause the knock-knees and bandy-legs that are 
so often seen in late cases of rickets. 

A good deal of discussion has been carried on as regards the 
cause of all these deformities. Some have contended for mus- 
cular force acting on soft bones ; others for simple weight — the 
bones, not being strong enough, yielding under the weight they 
are called to support. Both these forces are probably entitled 
to some consideration ; but the theory which attributes the 
curvatures to undue weight is no doubt the more important, 
and most of them may be understood and explained by a con- 
sideration of the direction in which the force has acted. In 
one case it may be the weight of the body in walking ; in an- 
other, that of one part of the limb upon the remainder, in cer- 
tain recumbent postures. In the arms it is due to those parts 
being used as a help to progression, the child moving on all- 
fours. In the thorax some have attributed the distortion to a 
combination of softening of the bones with collapse of the lungs, 
which is a frequent associate and consequence of rickets ; oth- 
ers to softening of the bone, and a yielding under the inspira- 
tory pull of the muscles. Of this, however, there can be no 
doubt, that the disease in the thorax is almost constantly asso- 
ciated with bronchitis and atelectasis, and that in the bones of 
the spine and extremities curvatures never reach any extreme 
form in such as have not been allowed to walk or sit up unduly. 

Another important point as regards the rachitic skeleton is 
that the bones are stunted in their growth, and in extreme 
cases the child may be severely dwarfed by this means. 



RACHITIS. 243 

Symptoms. — Rachitis is a non-febrile disease. The inflamma- 
tion which some pathologists maintain must accompany the 
bone changes which occur as a part of the malady is sub-acute, 
and does not become general enough to raise the body temper- 
ature except in rare and exceptional cases. Ordinarily the 
disease is insidious and slow in its development, occupying 
months in its gradual and progressive course, before even those 
changes occur in the skeleton which are so characteristic. 

The essential symptoms of the initial stage of rachitis are 
those of indigestion and intestinal catarrh, such as flatulence, 
unhealthy stools, poor and capricious appetite and all the 
accompaniments of malnutrition. 

The evidences of indigestion and malassimilation are accom- 
panied by marked mental characteristics. The child is cross, 
peevish and irritable. Its sleep is easily disturbed and it 
awakens often. Its appetite may be unimpaired or capricious, 
sometimes it is ravenous. But it does not grow. It does not 
care to play like a healthy child. On the contrary, it repels all 
attempts to amuse it as if annoyed by them. It resents being 
handled or fondled and cries when approached, as if it feared to 
be touched. It prefers to be let alone and will lie for hours in a 
state of listless melancholy, rather than sufTer the pain which 
comes from being disturbed. This soreness is partly muscular 
and partly due to the changes which are going on in the per- 
iosteum of the bones. 

Another and noticeable symptom of incipient rickets, and 
frequently the first one to attract attention, is sweating about 
the head. It perspires freely, both about the head and neck, 
especially about the former. 

This may occur when the child is awake and is independent 
of the temperature of the room or the abundance of clothing. 
It is, however, most marked when the child is asleep. Its pil- 
low is wet with perspiration and drops of sweat may be seen on 
the forehead and face. Cranial perspiration occurring habit- 
ually whenever the child sleeps is a very significant sign. It 
may not always point to rickets, but is always a dyscrasia. 

The abdomen early becomes distended by gases, and this, 
with enlargement of liver and spleen, produces the '' frog belly" 
so frequently seen when the disease is well marked. The veins 
of the temple and forehead are unduly prominent and some- 
times those also of the neck and thorax. The child is prone to 
kick off the bed-clothes at night as if the weight of the clothes 
was intolerable. 

But the most significant and certain of the early signs of 
impending rickets is found in the delayed evolution of the 
teeth. I do not refer altogether to the eruption of the teeth 



244 THE DISEASES OF CHILDREN. 

through the gums, although this has its significance, but to the 
whole phenomenon of teething. A perfectly healthy child should 
show some of the usual signs which accompany this process by 
the fifth or sixth month. If this age be reached and there be 
no increase of the salivary secretion ; no tumefaction of the 
gums ; no irritation of the nervous system accompanied with 
suggestive actions pointing- to the mouth as its seat ; if, in a 
word, there is no change in the inner contour of the jaw indica- 
tive of activity there ; and if this condition goes on to the 
seventh or eighth month, the watchful physician should be on 
his guard. If, in addition, cranial perspiration is present when- 
ever the child slumbers, and further, if the mental condition — 
the settled, characteristic melancholy — is apparent, we need not 
wait for further development to diagnose the disease. 

Another symptom connected with teething is often present 
in children in whom the disease has started after one or more 
teeth have erupted. It is the prolonged interval that elapses 
between the cutting of single teeth or pairs of them. These 
intervals are reasonably regular, as a rule, in healthy children, 
and any unusual delay in the continuance of the process of 
tooth evolution, after it has once begun, should not be allowed 
to pass unnoticed. 

These symptoms belong to the first stage and precede that 
of noticeable deformity. When this latter stage is reached, the 
most evident signs are to be observed in the head, ribs and 
radius. The head loses its vaulted form and becomes box-like. 
It is flattened both on top and sides. Its antero-posterior diam- 
eter is elongated. Its width is also increased. The size of 
the cranium is therefore large, but not usually so large as in 
hydrocephalus or hypertrophy of the brain. The sutures remain 
open, so that, between the illy-developed cranium and the 
equally ill-nourished brain, there is often fluid, simply filling 
up the space, and not the result of any inflammatory 
effusion. This condition is \.^xvi\^6. ''' spurious hydrocephalus ^ 
It frequently happens in rachitis that the cranium is unsym- 
metrical. 

I have noticed this particularly in the case of a child whose 
mother had the use of but one breast. This compelled the 
child to always lie on the same side while nursing and the pres- 
sure of the head against the breast had markedly flattened that 
side of it. 

But the most pathognomonic symptoms of rickets is caused 
by the enlargement of the epiphyseal ends of the ribs where 
they join the costal cartilage. This is, in most cases, very no- 
ticeable, and constitutes what is variously called the " row of 
beads," the " rachitic rosary," or the " rachitic garland." The 



RACHITIS. 245 

wrists also enlarge, owing to the effect of the disease on the 
epiphysis of the radius. 

Complications. — The rickety condition is always associated 
with general debility, and is often complicated with bronchitis, 
pneumonia, whooping cough, the eruptive fevers, tubercular 
disease of the thorax or abdomen, laryngismus and hydroceph- 
alus. Any of these disorders have an unfavorable effect on the 
progress of the malady, for whatever reduces the general 
strength and weakens the constitution, is certain to retard re- 
covery when it has once commenced. The changes which 
take place in the thoracic walls have an injurious effect on both 
the heart and the lungs. The heart is pressed upon, and after 
a time more or less hypertrophy is the result. In a case which 
the author has had under observation for some two years past, 
in a child now nearly three years old, there is considerable bulg- 
ing in the precordial region ; and the pulsations of the heart have 
never been below sixty since he was first seen, which was when 
he was about ten months of age. His respirations now average 
twenty. This child has passed through two serious attacks of 
bronchitis, during which his respirations were as high as eighty 
for several days, but he ultimately made a good recovery. The 
case is interesting as illustrating several points in the foregoing 
pages relative to the course and causation of this disease. The 
father and mother of the child are exceptionally robust and 
healthy. The father is over six feet tall, while the mother is 
but four inches shorter. Both are young, and this was their first 
child. A few weeks after he was born the mother was taken 
ill, and unable to continue nursing him. He was placed on the 
bottle and various baby foods given, but none of them satisfied 
his needs. He stopped growing, became fretful and peevish, 
cried whenever anyone looked at him, sweat a great deal about 
the head, and when I was first called to see him, he was, as 
stated above, ten months of age and weighed thirteen pounds. 
It was three months after the writer took charge of him before 
he gained a pound in weight. It seemed impossible to move 
him away from this fatal number. After a time, however, he 
slowly began to gain, until now at the age of four and one-half 
years he weighs twenty-eight pounds. 

A year ago, I delivered this mother of another son, and 
fortunately she was able to nurse it. This second child of 
these parents has never seen a sick day since birth, and is larger 
than his brother, who is older by something over two years. 

It would be unfair to conclude that, because one of these 
children was raised on the bottle and the other at the breast, 
that the bottle feeding was the sole cause of the rickets. I 
am not aware what food was first used in the case nor what 



246 THE DISEASES OF CHILDREN. 

judgment was exercised in its preparation, but in my opinion 
it was the food in the bottle and not the bottle itself that was 
to blame. 

The lungs are apt to suffer more than the heart in cases of 
rachitis in which the chest is distorted. Semi-collapse of cer- 
tain lobules is apt to occur, and even complete collapse of the 
thin edges of the lung is not uncommon. In such cases bron- 
chitis and pneumonia are very apt to prove fatal. 

Laryngismus stridulus is another very common and serious 
complication in rickets. Laryngismus is sometimes called 
" child crowing," from the peculiar noise which is made at each 
inspiration. The affection consists in a spasmodic closure or 
narrowing of the glottis, which greatly impedes respiration and 
while it lasts it seriously threatens life. As a rule, however, 
the attack lasts but a few seconds and is harmless. When the 
attack is severe and prolonged, there is a fixation of the dia- 
phragm, and of the respiratory muscles, and the thumbs and 
fingers become tightly flexed on the palms. A slight degree 
of cyanosis may occur and general convulsions may supervene. 

Prognosis. — So far as the disease itself is concerned, the prog- 
nosis in rachitis is good. Death rarely results from its direct 
effects. Owing to the depressed and narrowed condition of the 
thorax, the action of the heart and lungs is embarrassed, and 
any disease of the respiratory functions is consequently more 
serious in a child affected with rickets. Under these circum- 
stances, bronchitis and pneumonia are attended by increased 
dangers. Whooping cough also is much more serious when it 
complicates rachitis. If the cough be severe while the ribs are 
soft and yielding, and there be lateral depression of the thorax, 
the spasmodic cough produces great suffering and involves dan- 
ger. Measles, when attended by considerable bronchitis or 
broncho-pneumonia, is another of the dangerous inter-current 
diseases. Among the remote results of rachitis, which compli- 
cate the prognosis, and render it somewhat doubtful so far as 
longevity is concerned, is the danger to married females, from 
the deformity and stunted growth of the pelvic bones, should 
they become pregnant. Labor is often seriously complicated 
by distortion of the pelvis in women, who have been rachitic in 
infancy. The older the child is when rachitis begins, the milder 
is its ordinary course, and the less is the resultant deformity. 

Treatment. — That rachitis should be as prevalent among all 
classes of society, as is indicated, in the early part of the chap- 
ter, is an opprobrinin medicorinn, for if any disease is prevent- 
able it is this one. No well-fed child has rickets. It cannot 
be too emphatically impressed upon the medical student that 
whenever a child shows signs of rickets, an avoidable error in 



RACHITIS. 247 

its diet has been made ; and the first step in the way of treat- 
ment is to correct this error. It is neither an act of prudence 
or wisdom to delay a radical change in food. If the child has 
been nursed at the breast and under five or six months of age, 
the nurse should be changed; but if older than this, it should 
be placed on artificial food and part of its diet, no matter what 
particular cereal is used, should be of an animal nature. If 
cow's milk is tolerated, well and good; but if not, the juice of 
raw meat should be given — the meat juice being prepared as 
directed on page 6i. 

When the child gives evidence that it is not thriving on the 
particular food which has been selected for it, another must be 
chosen, regardless of preconceived opinions or notions. 

We have had the best success in rachitis with the Liebig 
food, in which the starch it contains has been converted into 
glucose. It so happens that we have always used the prepara- 
tion of malted food known as Mellin's, and after twenty years' 
experience with it we can say that we have never known an 
infant to become rachitic under its use, while we have known 
many to recover who had become rachitic under other foods. 

Cow's milk as an exclusive diet is in these cases inadmissible. 
Its tendency to form lactic acid simply feeds the morbid pro- 
cess. All foods requiring the addition of cane sugar, to make 
them palatable, are injurious for the same reason. If an atom 
of cane sugar be split in two, the result is an atom of lactic 
acid and an atom of alcohol. 

But lactic acid is already in excess in the blood, as we have 
seen, and is busy creating mischief in all the tissues. To add 
more is to add fuel to the flame. All forms of starchy foods 
and those requiring artificial sweetening are pernicious, and 
this is why the great majority of the so-called " baby foods " fail 
to meet the requirements of these cases. 

This subject is treated of so fully, however, in a preceding 
chapter that nothing further need be said here. Fresh air and 
sunshine are very necessary to the subjects of rachitis. Indeed, 
every hygienic measure available should be utilized, for there is 
really more practical value to be derived from them than from 
drugs. The latter are valueless without the former. While 
the bones are soft and yielding, great care should be exercised 
to prevent deformities. The patient should not be encouraged 
to use the limbs or bear weight upon them until they have 
become firmer. He should lie on an even and soft mattress, 
but one that is not heating to the body like feathers. Bathing 
the body occasionally with dilute hamamelis or alcohol is 
helpful. 

Inunctions of olive oil following the bath, are of service also. 



248 THE DISEASES OF CHILDREN. 

In craniotabes, the pillow should be of hair — soft and yet cool, 
and care must be taken that the yielding parts of the cranium are 
not unduly pressed upon. When curvatures are unavoidable, or- 
thopedic treatment will be necessary, but should not be resorted 
to until nature has had an opportunity to act alone, for in many 
cases, as the muscles strengthen, the bones will be brought into 
line. Cumbersome apparatuses that are heavy to carry are apt 
to do more harm than good. 

Medical Treatment. — Any one who has read the pathogen- 
esis of phosphorus could scarcely fail to observe the striking 
similarity between the symptoms of this drug, as observed in 
cases of phosphorus poisoning, and rachitis. It has produced 
osteomalacia in adults — a disease which in its course and nature 
is almost identical with the rickets of infancy. It has produced 
rickets in young dogs and rabbits, when given to them experi- 
mentally. It is logical, therefore, to expect that phosphorus 
would prove curative in this disease, and such is the case as 
demonstrated by all who have ever employed it. While there 
are other and valuable remedies to meet the various peculiari- 
ties and complications which are liable to arise in the course 
of the disease, there is no other single remedy that so fully 
covers the typical case, from its inception to its cure, as this 
one. 

But we do not get its best value when it is given in its simple 
and direct form. It combines too readily with oxygen to form 
phosphoric acid, to perform its highest functions. Its stability 
and effectiveness are greatly increased by adding it to lime, and 
forming the drug we know as calcarea phospJiorica, and in 
this preparation we have a remedy for rachitis which is par 
excellence. 

Its sphere of action covers the following symptoms, which 
are those of a typical case of the disease we are now consider- 
ing, to wit : Both fontanels open ; tardy dentition ; sweating 
about the head; abdomen ''pot-bellied ;" indisposition to be- 
ing handled ; soft, spongy condition of bone ; bones fragile, or 
easily bent ; settled melancholy, and, indeed, the whole cata- 
logue of symptoms which are so characteristic of these typical 
cases. 

Many of these symptoms are also covered by calcarea car- 
bonica, but not to the same extent and fullness. The latter is 
more useful in the incipient stage; the former after the disease 
has become fully established. Calc. carb. meets more directly 
the objective symptoms, while calcarea phos. more the subjec- 
tive ones. The first acts more on the blood and the soft tissues, 
the other the osseous, and the harder tissues. The one acts 
superficially, the other more profoundly. Whichever remedy 



A' A CHI TIS. 249 

is used, it must be given systematically and persistently for a 
long time. 

Silicia. — Here, as elsewhere in bone affections, this remedy is 
of the greatest value ; there are few cases of rickets which do 
not call for silicia at some stage of the treatment. I have ob- 
served, however, that when it is given for some time, and this 
regardless of the potency, there will appear a distressing, gnaw- 
ing pain in the stomach, which is relieved by eating. I have 
hitherto failed in relieving this by a simple discontinuance of 
the remedy. Nux vomica has oftener removed it than any other 
remedy, but not always. The appearance of this symptom 
must be the signal to abandon the remedy entirely. Its dura- 
tion is uncertain, but rarely exceeds a fortnight. The symp- 
toms calling for silicia are similar to those of calcarea carbonica, 
with the following exceptions : the body is much emaciated, 
but not soft and flabby ; it is '* scrawny," skin somewhat indu- 
rated, with tendency to boils. — Gilchrist. 

Other remedies that may be consulted are mercurius sol., 
colchicum, assafetida, and sulphur. 

For the complications which are so common, such as bron- 
chitis, pneumonia, etc., the indicated remedies should be given 
intercurrently with the constitutional remedy, for the rachitic 
condition, as indicated above. When laryngismus stridulus 
supervenes, it requires no different treatment than when the 
same thing occurs under other circumstances. See chapter on 
this subject. 



CHAPTER III. 

ACUTE TUBERCULOSIS. 

Definition. — This is a disease which consists of a deposition 
of gray granular matter, or miliary nodules, into the various 
organs and tissues scattered throughout the body. It should 
not be confounded with pulmonary phthisis, for the reason 
that while this condition may result in ulceration or destruction 
of the lung, it by no means follows that it always does so. On 
the contrary, while having many points in common, the two 
diseases are quite distinct and tuberculosis may invade nearly 
every other portion of the body, without affecting the lungs 
at all. 

It is a general disease affecting principally infants and chil- 
dren, and in most cases, although not all, is to be attributed to 
hereditary predisposition, 

''Phthisis" is a term used to indicate a tuberculous condi- 
tion of the pulmonary tissues, those tissues being principally or 
primarily affected ; while tuberculosis is employed to signify a 
general distribution or dissemination of tuberculous matter 
throughout the system, but affecting for the most part the lym- 
phatic glands. 

The word "tubercle " is a very vague one, and is used so 
differently by different authors, that it has almost ceased to 
convey any definite meaning, or indicate with certainty any 
special pathological process. 

The disease here referred to under the title of acute tuber- 
culosis, is one which commonly presents the features of an acute 
specific fever of indefinite type and without any special signs 
pointing to local mischief. Yet local mischief is going on 
apace ; histological elements in various tissues are undergoing 
pathological changes ; lymphatic glands are being gorged with 
"giant cells," and through the medium of the lymph channels 
the tissues generally are being filled with poorly organized and 
very vulnerable spherical cells which, on slight provocation, 
undergo caseous metamorphosis. 

The gray granulation is composed of caseous matter, which 
at first is firm and translucent, but in children it soon loses its 
translucence and turns yellow. 
(250) 



ACUTE Tl 'BER C UL OS IS. 251 

The nodules of gray or yellow granulations are of various 
sizes, from a pin's head to a millet seed, and are the result of 
a specific irritation of the endothelia of the lymphatics. Rind- 
fleisch describes the granule as a product of inflammation, and 
states that it consists in an increasing accumulation of leuco- 
cytes in the connective tissue of the parts irritated. As the 
lymphatics are everywhere, in all the membranes, blood vessels, 
nerve tissues and bones, as well as in the glands, so we may 
have anywhere or everywhere the presence of gray granular 
matter, ready at any time to cause irritation, inflammation and 
to finally, circumstances favoring, degenerate into suppuration. 
The presence of the gray granulation in any tissue is quickly 
followed by inflammation in the neighborhood of the growths. 
In the case of a serous membrane, such as the meninges of the 
brain or the peritoneum, lymph is quickly thrown out, and in 
time this exudation becomes caseous. When this occurs in 
the tissue of the lungs, bronchitis or catarrhal pneumonia is set 
up, and in case of a fatal ^.^rm\Vi^X.\or\, post-mortern examination 
shows degeneration of the nodules in every stage of progression. 
Ulceration and the consequent formation of tuberculous cavi- 
ties in the lungs are not common in early life, although they do 
occur in exceptional cases. 

In the intestines, the gray and yellow granulations occur, 
•especially in the smaller bowel, and involve principally the 
ileum and the part of the caecum in the neighborhood of the 
valve. The liver, the spleen and the kidneys are frequently the 
seat of these tuberculous deposits, the spleen being especially 
liable to attack. 

Causation. — Aside from heredity, it is useless at the present 
time to discuss the causes which lie at the foundation of acute 
tuberculosis. The present age will be known to the future his- 
torian of medical progress as the age of microbes. Every 
disease that human flesh is heir to is now popularly supposed to 
be due to some specific microbe, and in the opinion of the germ 
theorists acute tuberculosis is peculiarly and especially due to 
bacilli. 

To broach any other theory would be to go counter to this 
popular opinion, and would lay the author open to the pre- 
sumption of ignorance or to inexcusable skepticism. Never- 
theless, there are those high in authority who have not as yet 
accepted in full faith the idea that the living body is always, 
when sick, a prey to inferior and infinitesimal organisms. 

There would be an obligation to discuss the germ theory and 
prove or disprove its tenets, if its advocates based any modifi- 
cation of treatment upon it or helped to answer the question, 
" Provided it is true, what can we do about it?" 



252 THE DISEASES OF CHILDREN. 

There is, however, no answer to the query, and so we may 
as well admit that we do not know any more to-day about the 
actual causes of this disease than did our predecessors of a 
thousand years ago. Humiliating as it is to make so bold a 
confession, it is better to realize and face the truth, than to 
waste valuable time in the futile following of a chimera. 

Symptoms. — Children affected with tuberculosis,although often 
of delicate appearance, are not necessarily thin and feeble looking. 
In many cases the nutrition is good, and the child is considered 
in every way a healthy subject, prior to the development of 
the disease. Sooner or later, however, symptoms are noticeable 
pointing to disease of special organs. These symptoms may 
point to the brain or to the lungs, in which case we have such 
phenomena as is described under the head of tubercular men- 
ingitis or pulmonary phthisis. When the disease is general or 
not specially localized, we have only vague, indefinite and 
insidious signs to guide us in our diagnosis. 

General malaise, pallor, wasting, fatigue, want of appetite, 
slight fever, etc., etc., may mean much or little, and only close 
watchfulness and great acumen can construe them properly. 
Time, often, is the only aid to elucidate the truth. Sometimes 
a conclusion is scarcely reached before intolerance of light, 
drowsiness, squint, are noticed ; quickly followed by convul- 
sions, coma and death. 

Diagnosis. — As already indicated, the diagnosis of acute tuber- 
culosis is sometimes very perplexing. At best the symptoms are 
vague and indefinite ; the fever is rarely high, and in the early 
stages may be wanting altogether ; the gastro-intestinal symp- 
toms are usually well marked, but no more so than when occur- 
ring independently from tubercle. 

The disease with which it is most liable to be confounded is 
typhoid fever. This is especially the case w^hen the tubercular 
affection begins abruptly with high fever, headache and nose- 
bleed. But typhoid fever has a more regular gradation of tem- 
perature, and runs a more even and regular course generally. 

Besides this, tuberculosis is prolonged beyond the time when 
we ordinarily look for a fall in the temperature in typhoid cases. 
There is a peculiar distress in the face of a tuberculous patient, 
that is wanting in the other, and the child is dull and spiritless. 
The history of the case for sometime prior to the present attack 
is somewhat helpful. 

In tuberculosis there is usually a history of several attacks of 
diarrhea, which cannot be accounted for by errors in diet, and 
a gradual emaciation attended by mild pyrexia. In an infant 
there is frequently more or less edema of the legs. 



TABES MESENTERICA. 253 

If typhoid fever be excluded, and there is a history of grad- 
ual wasting, moderate pyrexia and edema of the lower ex- 
tremities, and more especially if the family history is not above 
suspicion, the diagnosis of tuberculosis is fairly warranted. 

Prognosis. — This is not usually encouraging. If the diagnosis 
of acute tuberculosis is clearly established, the chances of recov- 
ery are desperate. The early symptoms of the disease, as we 
have seen, are rarely sufficiently plain to indicate the real na- 
ture of the trouble, until the general system is filled with gran- 
ular deposits, and nutrition is irreparably impaired. 

Treatment, — When one member of a family has shown evi- 
dences of being tuberculous, the other members should be 
watched with the ^greatest solicitude, and if possible, placed 
under better hygienic influences and healthier environments, in 
the hope of anticipating and preventing the disease in them. 
The country is preferable to the city ; and a dry and warm 
climate better than a damp and changeable one. As soon as 
the first symptoms show themselves indicative of indigestion, 
catarrh or diarrhea, they should receive the appropriate reme- 
dies for these complaints. The diet should be made to exclude 
an excess of sweets and all fermentable matters. In a fully 
declared case of the disease, our remedies should be given, not 
alone in the hope of arresting the formation of tubercles, but 
also to put a stop to enfeebling complications. The remedies 
which have received most commendation in the treatment of 
acute tuberculosis are iodium, sulphur, kali iod., baptisia, lyco- 
podium, mercurius and calc. phos. 

For further elucidation of this subject, the reader is referred 
to the chapter on Pulmonary Phthisis. 

TABES MESENTERICA. 

Definition. — By this term is indicated a tuberculous condition 
of the mesenteric glands. It is not to be understood that the 
tubercles in this disease are limited to these glands; for tabes 
mesenterica is rarely, if ever, a simple affection. 

Indeed, when tuberculous nodules are sufificiently large or 
sufificiently numerous to be recognized in this locality, they are 
usually scattered, at the same time, generally throughout the 
system, and a case of acute, general tuberculosis would be 
phenomenal, which did not, at the same time, involve the mes- 
entery. 

It is, however, only in a small proportion of cases of tubercu- 
losis that the mesenteric glands become sufficiently indurated 



254 THE DISEASES OF CHILDREN. 

and swollen to attract attention or complicate the course of 
the general disease. 

Symptoms. — The most prominent features of tabes mesen- 
terica are general emaciation and a tumid abdomen. 

The emaciation is sometimes startling. *' The sub-cutaneous 
fat disappears rapidly. The skin is thin, flabby and inelastic ; 
round the limbs, it is loose and hangs like a bag ; when taken up 
between the fingers, it retains the fold raised in the lifting. In 
the beginning, the muscles can be recognized ; afterwards even 
they emaciate to such an extent that their outlines disappear, 
and those of the bones are distinctly perceptible. The eyes lie 
deep in the orbits and have a peculiarly dry and hungry look. 
The bones of the face, with the thin, flaccid, dry and scaly skin 
over them, take on a terribly senile expression. The surface is 
mostly cool, the limbs are cold, the cutaneous veins very dis- 
tinct and blue, much dilated over the chest and still more so 
over the abdomen. The voice is thin and tin-like, the cry 
mostly tearless, the pulse slow (from the heart-muscle), or more 
frequently rapid, thin and compressible. The lymph bodies of 
the neck and the inguinal region, sometimes also the axilla, are 
tumefied." This picture of tabes mesenterica is more or less 
true to all cases. But the disease is not without variations. In 
some cases the appetite is wanting and in others it is voracious. 
Some have diarrhea and others do not. In all cases the stools 
are fetid. In the majority of cases, there is severe intestinal 
catarrh, attended with offensive discharges. The peculiar foul 
odor is largely due to acids formed by the fat, which has not 
been absorbed, sulphides, and other products of putrefaction, 
The stools are mostly large and expelled with an instantaneous 
gush. Fever is not always present, and in some cases the tem- 
perature may be subnormal. The tumid abdomen is sometimes 
sensitive to touch, while in others it is painless. In exceptional 
cases, the abdominal walls are not particularly distended and 
they may even be retracted ; but in a typical case, the belly is 
swollen in fearful contrast with the atrophied state of the mus- 
cles of the thorax and the limbs. When tubercular peritonitis 
supervenes, as it sometimes does, the abdominal pain on pres- 
sure is exquisite. 

When the abdomen is tympanitic, the superficial veins are 
dilated and prominent. By elevating the legs and relaxing the 
abdominal walls, tuberculous nodules can be felt, sometimes 
superficially and again deep down, along the vertebral column. 
The tumefied glands attain a size varying from that of an almond 
to a pigeon's ^g'g, or larger, and occasionally from the aggre- 
gation of several enlarged glands, a mass is formed double the 
size of the child's fist. In many cases the glands, however 



TABES MESENTERICA. 255 

large, are difficult of detection, for the reason that they are 
covered and concealed by coils of intestine. When the abdo- 
men is supple and relaxed, however, and the enlarged glands 
are in the neighborhood of the umbilicus, careful palpation 
will generally discover them. The variableness of the distinc- 
tive symptoms in different cases would render the diagnosis 
very difficult, if only those of a local character had to be 
depended upon. The history of the case and the concomitant 
symptoms must all be given due heed, and even then, there 
may be trouble in reaching an early conclusion. If the bowels 
are constipated the intestines are apt to be filled with gas, and 
this should be remedied before any attempt is made to palpate 
the abdomen. In advanced cases, the cheesy glands infect the 
the peritoneum in their neighborhood, and adhesions occur 
between the intestinal coils, and between them and the abdom- 
inal wall. Irregular distension of the abdomen is thereby 
occasioned and much intestinal gurgling and rumbling. Ulcer- 
ation of a tuberculous mesenteric gland occasionally occurs, 
with perforation of the intestine. 

Prognosis. — When the tuberculous infiltration is largely or 
wholly limited to the glands of the mesentery, the prognosis is 
by no means hopeless, but the more the general system is 
infected, the more serious and desperate the case becomes. 
Still no case should be abandoned as hopeless, however dis- 
couraging it may appear, for it is never possible to determine 
except by an autopsy, how much or how little tuberculous infil- 
tration exists, and the severity of the symptoms are not a safe 
criterion upon which to base a judgment. 

Duration. — These cases may be acute or chronic, and on this 
fact depends the length or brevity of the attack. Acute cases 
may last for several weeks, or even months, after the symptoms 
have become sufficiently pronounced to permit of a diagnosis. 
Chronic cases may last for months or even years. 

Treatment. — Infants and children of the strumous habit 
should receive especial care whenever they show the first symp- 
toms of diarrhea. Any irritation of the intestinal tract is liable 
to affect the neighboring glands, and cause them to swell. For 
this reason great care should be taken to exclude everything 
from the diet that might give rise to irritation of the bowels. 
They should not be allowed to become constipated, for this, 
also, is a source of glandular engorgement. 

The abdomen should be swathed in flannel, for these ema- 
ciated patients are very easily chilled. They should be warmly 
clothed, and then kept much in the open air. They should be 
rolled about in an easy carriage, with an avoidance of sudden 
jars and joltings. If the disease develops in a nursling, the 



256 THE DISEASES OF CHILDREN. 

quality of the nurse's milk should be determined, and changed 
if necessary. If cow's milk is used it should be peptonized, for 
the digestive powers of the patient are more or less impaired. 
The wasting can be combated, to some extent, at least, by in- 
unctions of olive oil or cocoa butter. If the abdomen is ten- 
der and painful, poultices of flaxseed meal are to be employed. 
Bathing with water should be done sparingly, and only as 
needed for the sake of cleanliness. 

Remedies. — The leading remedies for tabes mesenterica are : 
arsenicum iod. ; arsenicum alb. ; argentum nitras ; calcarea 
iod. ; calc. phos. ; mercurius iod. and sulphur. Other remedies 
than these may be studied, but the foregoing should be printed 
in full capitals to properly emphasize their worth. 

The selection of the particular one for the case in hand will 
be successful only by a close and careful study of their symp- 
tomology, and of the distinctive features of the case itself. 



CHAPTER IV. 

SCROFULA. 

Definition. — The word scrofula is almost obsolete and is so 
indefinite and meaningless that it cannot long be retained in 
the nosological list. A much better term is cervical adenitis, 
or would be if the disease were confined to the glands of the 
neck. Formerly the word was used synonymously with 
"struma," and was applied to chronic inflammation of the lym- 
phatic glands, wherever situated, which showed a tendency to 
spread by local infection and prone to caseous degeneration. A 
scrofulous individual was one who was liable, from the slightest 
exciting cause, to have enlargement of the glands, either of the 
neck or elsewhere, which inclined to suppuration, by reason of 
defective power of vitality. The term "tubercle" was lim- 
ited to the gray granulation and caseous nodules affecting the 
lungs, viscera, and serous membranes. The two diatheses were 
regarded as closely related, but not identical. Latterly, how- 
ever, there seems to be a disposition to regard the two affec- 
tions as different manifestations of one and the same morbid 
process, and in some recent works the term scrofula is omitted 
altogether. It is not with any disposition to revive or to coun- 
tenance a decaying bit of silly nomenclature that it is here re- 
tained, but because it has not as yet passed out of use to such an 
extent but that certain pathological conditions of importance 
to the student and practitioner might be overlooked or neg- 
lected, if discussed under another name. Besides, it scarcely 
seems appropriate in a work of this practical character to spend 
either space or type in combatting habits and prejudices that 
are sanctioned by time and usage, and whose continued em- 
ployment can result in neither confusion nor harm. For the 
sake of explicitness, and to indicate the scope of the word 
scrofula as here used, we cannot do better than to adopt the 
definition of Meigs and Pepper : " We, ourselves, would be un- 
derstood to employ it much in the old sense, to indicate a pe- 
culiar constitutional condition in which there is a 'vulnerable' 
or irritable state of the lymphatics, which renders them liable 
to become enlarged from trifling causes, and at the same time 
indisposed to healthy reparative action, and which is also apt 
to manifest itself by various obstinate chronic inflammations of 
D.C.— 17 (257) 



258 THE DISEASES OF CHILDREN. 

the skin, mucous or synovial membranes, or bones." It is uni- 
versally admitted that scrofula is intimately related to tubercu- 
losis. It often happens that the children of tuberculous parents 
are scrofulous. And it is an unexplained fact that such chil- 
dren are scrofulous and not tuberculous. That is to say, the 
"scrofulous" child is very subject to glandular swellings, espe- 
cially of the neck, and may have suppurative inflammations of 
the joints, and yet never have any distinctive development of 
other tuberculous symptoms — such as cough, emaciation or me- 
ningeal trouble. This is not always so, for persons who have 
been scrofulous in early life, frequently become the victims of 
tuberculosis subsequently. That the two diatheses, although 
manifestly similar in many respects, are not precisely identical, 
is shown by many well-recognized facts. We can here only 
draw attention to a very few of them. 

Scrofula is, far more markedly than tuberculosis, a disease of 
early life. The pathological tendencies of the two diseases are 
very different. Scrofula affects, more particularly, the super- 
ficial glands, the bones, the skin and the adjacent mucous and 
synovial membranes ; while tuberculosis affects, by preference, 
the serous membranes, the lungs, the solid abdominal organs, 
and the alimentary and respiratory mucous membranes. 

Causes. — What has been said relating to the obscurity that 
surrounds the etiology of tuberculosis, is equally true of the dis- 
ease under consideration. All of the theories which have, from 
time to time, been brought forward to account for its presence, 
are but idle speculations. We shall probably not reach a per- 
fect explanation of it until we are able to explain and under- 
stand life itself. What life really is, constitutes a question 
which is no nearer a solution to-day than it was in the very 
beginning of time ; it is only the manifestations of life that are 
observed ; its essence would seem, in the very nature of things, 
to be undiscoverable. Scrofula is one of the many things that 
disturb and derange the normal condition of life manifestations, 
and do so in a tolerably regular and uniform manner, so that 
when we have a certain aggregation of symptoms, we call the 
disease by this name, and are able to differentiate it from 
all other diseases. As in the case of other cachexias, the actual 
disease, while undoubtedly hereditary, is not itself transmitted 
from parent to child, but merely so strong a tendency to its 
development that in some cases no care or favorable hygienic 
influences will overcome it. The causes which tend to thus 
develop it, act by impairing the nutrition, and include such 
influences as insufficient and improper food, protracted expos- 
ure to damp, cold and especially to vitiated atmospheres, attacks 
of certain diseases, which, like measles, typhoid fever and 



SCROFULA— SYMPTOMS. 259 

chronic malaria, exercise a remarkably injurious action upon 
nutrition. 

Symptoms. — In the majority of instances, symptoms of scrof- 
ulosis appear in infancy, and usually the skin is first affected. 
There are various eruptions, chiefly on the head and about the 
nates and genitals, which some observers have thought, but 
erroneously, to be pathognomonic of the disease. As a matter 
of fact, it would seem there is little, if anything, in the eruption 
itself to distinguish it from a similar one in a non-strumous sub- 
ject. Of all forms of skin eruptions, eczema is probably the 
most common. The eruption is tardy in development, runs a 
slow chronic course, is very intractable, and is prone to cause 
troublesome ulcerations of the skin. It is especially apt to 
occur about the nose and lips, ears and scalp. The secretions 
from the nasal mucous membrane and from the mouth, are apt 
to excoriate the adjacent skin and form eczematous sores. In 
the same way a chronic discharge from the ear may give rise to 
an eczema of the meatus and surrounding parts, inconsequence 
of the irritating nature of the discharge. Scrofulous eczema 
has frequently a peculiarity that may serve to distinguish it 
from the non-scrofulous variety, viz.^ the fluid which oozes out 
is thick and semi-purulent, instead of being serous, and as it 
dries it forms yellow crusts. The eczema and impetiginous 
eruptions, so common about the nose and mouth of weakly 
children, are fertile sources of glandular enlargement. They 
are very obstinate and hard to cure, so long as there is any dis- 
charge from the nose. 

Affections of the eye are very common, very intractable and 
apt to relapse. They do not, however, as a rule, lead to serious 
damage. 

Catarrhal inflammation of the middle ear is very frequent in 
strumous children, and is often associated with catarrh of the 
eustachian tube, and the fauces. More or less deafness may 
be produced. At a later stage the discharge may become pur- 
ulent and affect the petrous portion of the temporal bone. The 
membrana tympani is generally perforated. 

Chronic enlargement of the tonsils is very common in these 
cases, and may occur in infants under a year ; but more often 
decided hypertrophy is not noticed before the child is two or 
three years old. 

A catarrhal state of the mucous membrane lining the vulva, 
vagina, and more or less the urethra, is by no means uncom- 
mon in strumous girls of two to seven years of age. The dis- 
charge from these parts which ensues is irritating and exceed- 
ingly annoying. If considerable, it may be semi-purulent or 
bloody. In very young girls the discharge proceeds from the 



260 THE DISEASES OF CHILDREN. 

mucous membrane anterior to the hymen, and is, therefore, 
quite accessible for local treatment. 

Among the most formidable of the affections of these stru- 
mous cases, are diseases of the bones and joints. Caries of the 
vertebrae and of the long bones, such as the phalanges of the 
fingers, the ribs and the sternum, are common, and of these, 
caries of the phalanges of the hand, or metacarpal bones, are 
most so. These bone affections are very rare in persons who 
are not scrofulous. The synovial membranes, especially those 
of the knee and hip-joints, are very liable to take on scrofulous 
inflammation. When the disease attacks the knee, the constant 
activity of the joint usually precipitates a much earlier and 
more active form of inflammation than characterizes the affec- 
tion when fixed glandular structures are alone involved. 

The suppurative action causes enormous swelling of the 
joints ; erosion and caries of the osseous articular surfaces su- 
pervene, from a consecutive or simultaneous deposit in the 
articular surfaces, and their investing soft parts. Obstinate 
hectic fever ensues, and the patient may be considered fortu- 
nate in escaping death at the expense of a permanent anchy- 
losis of the joint. When the hip-joint is attacked, the case is 
still more painful, more serious and disastrous than in case of 
the knee, and recovery is slow and tedious at best, with gener- 
ally a shortened limb, and a more or less broken constitution 
for the balance of life. 

But the most common of all the lesions of scrofula, and the 
one most characteristic, is found in connection with the lym- 
phatic glands. Sometimes a single gland, but more often several 
of them, become enlarged, and after remaining swollen for a 
longer or shorter time, suppurate ; the skin gradually becomes 
undermined and breaks ; the broken-down glands discharge, and 
a sinus is formed, which eventually cicatrees, after many months, 
perhaps years, of chronic suppuration. 

The cervical glands are far more frequently affected than the 
glands in other regions. 

The glandular enlargement, in most cases, is very insidious, 
is quite painless, and is free from any local tenderness. The 
size and situation of the affected glands necessarily vary ; a 
single gland only may be involved, but more often several 
glands in close proximity are enlarged. 

This enlargement is essentially chronic, and the glandular 
tumor may remain for months, readily seen and felt, but giving 
the child no inconvenience, and without the slightest pain or 
tenderness. The ultimate result of this enlargement is prob- 
lematical. The gland may remain in a swollen condition for 
weeks or months, and then gradually the enlargement may 



SCROFULA— TREATMENT, 261 

disappear. Midway in the effort at resolution it may take on 
inflammatory action, and proceed to suppurate. The older the 
child and the better its general health, the better the prospect 
that the chronic glandular tumor will eventually disappear. 
After puberty the tendency to suppuration is much less than 
in early childhood. The more superficial glands are much 
more liable to break down and suppurate than are those which 
are deep seated in the fascia or under it. The bronchial and 
mesenteric glands appear to suppurate less often than the ex- 
ternal glands. The axillary and the inguinal glands frequently 
enlarge as well as the cervical, but not so often, nor do they 
show an equal tendency to suppuration. 

Among the exciting causes of glandular enlargement vacci- 
nation should be mentioned in order to correct a common 
notion, that when such an accident occurs it is the result of 
impure virus. There is no good ground for such a belief, for 
the reason that even in apparently healthy subjects, more or 
less tumefaction of glands is known to take place when the 
virus is above suspicion. 

In cases of this kind there is a probability of a hitherto unno- 
ticed strumous condition, that only required some irritant to 
awaken it into life and activity. On the other hand, the subject 
may be entirely free from any such scrofulous or strumous 
taint, as explained elsewhere (see Adenitis). 

Prognosis. — In most cases of scrofula a guarded prognosis 
should be given. Individuals, especially children, who are sub- 
ject to glandular enlargements are always delicate and easily 
upset by influences, that in healthier organizations w^ould pass 
unnoticed. Sometimes, indeed often, these strumous cases get 
along well, if once the critical periods are passed. Dentition, 
and afterwards puberty, however, are trying ordeals for these 
cases to pass through, and it must not be forgotten that scrof- 
ula is so closely allied to tuberculosis that the one is very apt, 
on slight provocation, to glide into the other. 

Treatment. — The treatment of scrofulosis naturally divides 
itself into two stages, the stage of dyscrasia, or predisposition, 
and the stage of development, or of glandular affection. In both 
stages the treatment must be both hygienic and medicinal, and 
in case of suppuration operative measures are to be added. 

The principal indication of a hygienic nature is to rid the 
system and keep it rid of all preventable sources of irritation. 
Scrofulous children are proverbially cold-blooded, and need 
to be warmly clad. Flannel should be worn next the skin at all 
seasons, or if the skin is too sensitive for this, a cotton gar- 
ment may be worn next the body, and flannel over it. The 
feet should receive extra care, and precautions taken to avoid 



262 THE DISEASES OF CHILDREN. 

getting them wet and chilled. Scrofulous children do not bear 
well confinement indoors, and should be kept out in the air 
and sunshine. Where it is possible, they should be taken to 
the seashore and be allowed to go into the sea water. The sea 
air is better than mountain air. 

There is nothing new to be said in this connection with refer- 
ence to diet, except that it should be plentiful, of proper qual- 
ity, and adapted to the digestive powers of the individual in 
question, age and development being duly considered. Chil- 
dren who have passed the nursing age, will be benefited by 
being given a small quantity of cod-liver oil two or three times 
daily. 

It has long been a common domestic practice to give strumous 
children some sort of fat, such as bacon or cream. They seem 
to crave it, and ordinarily digest it. There is no form of fat 
equal to cod-liver oil. It is difficult to say just how it acts, 
but the consensus of the opinion of the authorities of all coun- 
tries and of all medical schools speaks in its favor. 

The stage of development of glandular disease presents defi- 
nite indications for treatment, and the employment of thera- 
peutic measures. It is only occasionally that cases are brought 
to us soon enough to prevent glandular enlargement. In the 
majority of instances we are face to face with glands already 
tumefied, if not inflamed; and the problem before us is not one 
of prevention, but relief. The object of treatment is two-fold : 
first, to prevent, if possible, suppuration or caseation ; second, 
if this is impracticable, to secure a speedy and thorough evacua- 
tion of the gland, or what is now an abscess, in order to prevent 
the tubercular matter being carried to other parts. It is not 
always an easy matter to determine the question whether sup- 
puration or caseation has not already commenced, and pro- 
ceeded so far as to be incapable of arrest. Dr. Gilchrist says : 
" The presence of pus may be suspected, when there has 
been a more or less active inflammation which apparently 
subsides without a reduction of the glandular swelling; in su- 
perficial glands, fluctuation can usually be detected ; in deep 
structures the fact is to be determined in accordance with the 
principles of surgical diagnosis. 

" Suppuration, therefore, is usually readily determined. It is 
quite otherwise, very often, in the case of caseation. I believe that 
in the majority of instances, suppuration antedated caseation. 
When, therefore, there is a history of long duration of a gland- 
ular swelling coming on, with inflammation, the gland subse- 
quently having become smaller, yet remaining notably enlarged, 
the swelling being firm but not painful, and there having been 
no discharge of pus, it is altogether probable that caseation has 



6- CR OFUL A — TREA TMEN T. 2()o 

become established. So, also, on the other hand, if we find a 
case in which there is a history of slow, painless, non-inflam- 
matory glandular swelling, usually multiple, the glands being 
quite firm, with a tendency to an increase in the number of 
these enlargements, caseation may be considered as estab- 
lished. 

If a case is seen at the beginning of the glandular enlarge- 
ment, its fate practically depends upon the skill of the physi- 
cian. If he is a master of his calling, he can generally prevent 
further development, if he so wishes ; if he desires to promote 
a destruction of the gland, he has means to establish suppu- 
ration. Some will prefer the former, esteeming it a rational 
cure ; others prefer the latter method, desiring to eliminate 
what is held to be a concrete infecting principle, which happy 
circumstances have localized and placed in their power. If 
there is the faintest symptom of suppuration, the latter course 
must be pursued ; without indications of suppuration, my opin- 
ion inclines to the former method. 

To prevent suppuration, reliance must be placed entirely 
upon remedies, and the first in the list will be hepar sulphur 
and merciirius vivus, calcarea carbon., or baryta carbon, as sec- 
ondary resources. If there is a tendency to suppuration, /^^/^r 
sulphur again comes to the front, and the question as to the 
employment of poultices comes up. Suppuration, if too exten- 
sive, may precipitate the very catastrophe which it is desired 
to avert, viz., the dispersion of the tubercular mass. For this 
reason, among others, it is not deemed best to use poultices. 
Sidney Ringer, Hartshorne, Treves, and other waiters, have 
adopted Jicpar sulphur as a remedy of the first importance in 
promoting suppuration, and the former esteems it of particu- 
lar value in the early stages for its efificiency in suppressing the 
tendency to it. 

Fluctuation having occurred, and the evidences of the pres- 
ence of pus being conclusive, the tumor must be evacuated. 
To allow the abscess to discharge spontaneously is to insure a 
large, ill-looking scar, a very unnecessary loss of tissue, and to 
'expose the patient to the danger of dispersion of the tubercu- 
lar matter. The only question is whether to open the gland 
by a free incision or by aspiration. The more acute the abscess, 
the stronger are the indications for free incision. In chronic 
cases, as psoas abscess {g. v^, aspiration had better be employed, 
or some other method which equally prevents the admission of 
air. Under either circumstance, however, incision or aspiration, 
owing to the intolerance of the strumous individual there must 
be no rough handling or squeezing. 

In cases of caseation, hepar may be given to promote sup- 



264 THE DISEASES OF CHILDREN. 

puration, or a fine seton may be passed through the gland. 
When the glands are superficial, freely movable, with no attach- 
ments to the skin or deep parts, enucleation has been practiced 
occasionally with very good results. The skin is incised and 
the gland peeled out ; if found attached, as often occurs, even 
though palpation failed to show such attachment, the attempt 
must not be made. The operation is a slight one, when the 
indications exist, but it may be quite formidable in its results, 
at least if violence is used." 

Therapeutics. — The remedies most serviceable in scrofula are 
given in their alphabetical order, although not in the order of 
their relative therapeutic value. The list is incomplete, for 
there is scarcely another malady in which so large a number of 
remedies may be needed in the course of its progress. A thor- 
oughly complete list would very nearly exhaust the resources 
of the materia medica. 

Arsenicum. — Some authorities regard this remedy as of the 
highest value. Goullon says : ''Arsenicum does not act directly 
or specifically upon the morbid product, but upon the healthy 
tissue, the vital energy of which it increases and which it 
enables to resist the pathological element. Restoring general 
health, it becomes one of our surest remedies to counteract the 
development of neoplasmata." The waxy complexion, bodily 
restlessness, weakness, tendency to exhausting diarrheas and 
general aggravation from cold, are the more prominent indi- 
cations. 

Baryta. — The symptomatology for clinical purposes of the 
carbonates and muriate of baryta is quite similar, so that the 
drug is often given in one form or the other indiscriminately ; 
the muriate, I think, is generally preferred, and is credited with 
a prompter action, and one of longer duration. There is phys- 
ical and mental debility, with atrophy, and bloated abdomen. 
The glands are swollen, hai;d, indolent, and have a tendency to 
caseation or cretaceous degeneration, rather than suppuration. 
It seems to be for those of adult years what calcarea is to chil- 
dren. The face is usually disfigured by eruptions of various 
kinds, but there is little painfulness — at most a soreness or 
stiffness of the part. 

Belladonna. — This remedy is more useful in cases of an acute 
character, in which the glands become inflamed, rapidly suppu- 
rate, and the lymphatics are seen to be inflamed by the red, 
swollen streaks running to and from the gland. There is much 
pain and heat in the gland, and some considerable fever ; the 
pus is thick and yellow, and much less in quantity than the 
degree of swelling and local disturbance would seem to 
premise. 



SCROFULA— REMEDIES. 265 

Calcarea Carb. — Malassimilation ; tardy development of bony- 
tissue ; large head, with open fontanels; sweating about the 
head and neck when sleeping; feet and hands cold and damp; 
the perspiration not smelling badly, nor does it make the parts 
sore; bloated, protuberant abdomen ; glandular swellings com- 
mon, suppurating slowly, without pain, and discharging thin, 
inodorous pus, or yellow, bad-smelling, and excoriating pus. 
The face is pale and puffy, the bowels easily deranged; takes cold 
on slight exposure. In fact, the remedy is the typical one for 
scrofulosis in children, whether the disease be latent or active. 

Even without marked symptoms, as above, the flabby skin 
and the want of firmness in the flesh, so often seen before the 
active development of scrofulous affections, will call for this 
remedy above nearly all others. It is also particularly useful 
when there are indolent glandular swellings, small " kernels,'* 
as they are called, with a tendency to caseation. 

Calcarea Phosphor. — This remedy resembles the last, but 
seems more suitable for those who have passed infancy and 
childhood, and are approaching, or have entered upon puberty. 
There is emaciation, a dirty-white or brownish complexion,, 
with difificult teething in childhood, and much fetid diarrhea. 
The deeper glands are oftener affected, with a particular ten- 
dency to enlargement of an abscess of the mesenteric glands, 
and to psoas abscess. 

Graphites. — Eczematous eruptions, particularly about the 
hairy parts, as the head ; red, scurfy eruptions on the eyelids, 
with loss of the eyelashes ; glandular swellings, indolent, but 
soft, the suppuration being slowly established, the pus smelling 
like brine ; the pus is thin, yellow, and excoriating ; the glands 
discharge through numerous fistulas, and are very slow in heal- 
ing. The formation of deep, sore fissures or cracks, in the flex- 
ures of the joints, particularly the fingers, is quite pathogno- 
monic. I have seen them in the groins of children, exte-nding^ 
quite through the skin, with little soreness or inflammation. 

Hepar Sii/ph. — The symptoms of the dyscrasia are very simi- 
lar to those calling for graphites, the glandular swellings run a 
more acute course, and suppuration is of a rather better char- 
acter. The chief indication for this remedy, and one which no 
other remedy seems to fill as perfectly, is to promote suppura- 
tion when once it commences or seems inevitable. In some cases 
in which I have used it for this purpose, I have been surprised 
to find that the action was curative, resolution occurring with- 
out suppuration ; I am utterly unable to tell under what cir- 
cumstances this action is secured ; it has always been unex- 
pected. When suppuration threatens in a painfully swollen 
gland, a few doses of hepar frequently have the effect to 



26(3 THE DISEASES OF CHILDREN. 

dissipate the pain, and at the same time to wonderfully hasten 
the pointing of the abscess. 

lodium. — Dark, scrawny habit, extreme emaciation, yet with 
ravenous appetite ; general glandular enlargement, the swell- 
ings not being large, but hard and firm. When suppuration 
occurs, the pus is in large quantities, and quite laudable in ap- 
pearance. While small lymphatic glands are liable to tumefac- 
tion, others, such as the mammae, are prone to atrophy and 
disappear. 

Mercurius. — Emaciation and dyscrasic appearance, with per- 
spiration on slight exertion ; painfulness of the bones and deep 
parts, particularly at night, after going to bed. Malaise and 
feeling of illness or prostration, almost indescribable. 

Sulphur. — This is one of our most important remedies in the 
dyscrasia of scrofulosis. It is rarely indicated when the disease 
becomes active. The face has an old, drawn look; the fingers 
are disfigured by hangnails ; the soles of the feet are so hot 
that they are kept uncovered at night. There is a tendency to 
many forms of chronic, painless eruptions ; the bowels are 
always out of order, either constipation or offensive diarrhea 
existing ; nocturnal enuresis is common. The prevailing char- 
acteristic is mental and bodily indolence. 



CHAPTER V. 

INFANTILE SYPHILIS. 

When syphilis is acquired in infancy or childhood, its man- 
ifestations do not differ materially from those of the same 
disease occurring in maturity. With the primary lesion or 
chancre, therefore, the pedologist has nothing to do ; nor with 
the secondary and tertiary symptoms, as they develop them- 
selves subsequently. 

It is only with hereditary syphilis, as manifested before, or 
soon after birth, that we need concern ourselves. As is well 
known, syphilis is a prolific cause of still-births, premature 
labors and miscarriages. 

Occasionally it happens that the disease shows itself at the 
time the child is born, but more often an interval of a few 
weeks, and even several months, may elapse before this occurs. 
When it does, a rash makes its appearance, and certain symp- 
toms of unmistakable import follow in pretty regular succession. 

We do not propose to enter into a discussion of the vexed 
questions which have given rise to so much controversy, as to 
modes of communication, order of phenomena, etc., etc. The 
following facts, briefly stated, are generally accepted by the 
profession, and are necessary to be understood because of their 
medico-legal bearing, and for other reasons as well. 

The disease may be communicated at the moment of concep- 
tion by the syphilized condition of either parent. 

A syphilized mother is supposed to communicate the disease 
in a more virulent form than the father, and that blight and a 
premature birth are more likely to occur where the mother, 
rather than the father, is at fault. Both parties being diseased 
at the time of conception, blight and abortion are probable, if 
not a certainty. Both parents may be free from taint at the 
time of conception, and yet the child be born syphilitic from 
the mother's subsequent contamination, provided the contami- 
nation occurs prior to the sixth month of pregnancy. After the 
sixth month the child in utero seems to be in less danger of 
infection. If the father alone is at fault at the time of con- 
ception, he may procreate a tainted offspring, which in turn 
may contaminate the mother, without any primary experience 
with the disease on her part. 

(267) 



268 THE DISEASES OF CHILDREN. 

Parents recently syphilized, though apparently relieved and 
free from any diseased appearance at the time of conception, 
may propagate a syphilized offspring. 

Physicians are often asked to answer the question as to 
the precise date, or limit of time beyond which such parents 
may consider themselves reasonably exempt from risk to any 
future offspring, but this question it is impossible to answer 
with certainty. The time varies in different cases. In a gen- 
eral way, it may be stated that parties lately syphilized should 
not risk procreation under twelve months after the last disap- 
pearance of syphilitic symptoms. This is only an approximate 
rule and cannot be taken as the limit of absolute safety in all 
cases, for trouble may come after a much longer delay, and in 
some cases there is no safe period at all. It should be stated 
in this connection, that the transmission of syphilis to the off- 
spring is not inevitable, when the parents, one or both, have the 
disease, and that the aptitude to transmit the disease decreases 
spontaneously, in many cases, with the lapse of time, and this 
tendency to spontaneous diminution of the activity of the 
virus is greatly aided by intelligent treatment. 

Syjnptoms. — As a rule the specific symptoms are wanting at 
birth and do not manifest themselves until from ten to thirty 
days have elapsed. The infants are, to all appearances, well 
born and free from any taint whatsoever. Oftentimes, how- 
ever, the new-born infant shows bad development, with a dirty 
brown or copper-colored skin, and a scaling cuticle. Such an 
infant is apt to be atrophied, with a shriveled skin and features 
pinched and old-looking. In the worst cases, the entire body 
may be covered with moist and brownish scales or crusts, and 
here and there blebs containing serum or sero-purulent matter. 
Such cases as these take food badly and generally die soon from 
exhaustion. The appearance just described is called syphilitic 
pemphigus. It presents itself first on the palmar surface of 
the hands and soles of the feet, and subsequently on other parts 
of the body. If the eruptive process is delayed to a later 
period, the appearances will be the peculiar coppery blotches, 
with or without papular elevations. The mucous outlets, such 
as the mouth, the nose and the anus, are apt to be fissured and 
condylomata are common. The fissures or rhagades are very 
painful and bleed when their edges are put upon the stretch, as 
in feeding or at stool. An obstinate and distressing coryza is 
another symptom that is rarely absent. With it there is a 
nasal discharge, more or less copious, either thin and excoriat- 
ing or thick and muco-purulent, that poisons the adjacent skin, 
forming ugly sores, while it blocks up the nares with thick 
crusts that greatly embarrass the respiratory function. In some 



INFANTILE Sl'PHILIS— PROGNOSIS. 269 

cases a combination of snuffles and condylomata is all there is 
to designate the affection. The coryzal discharge is not usu- 
ally attended with ulceration of the mucous membrane, or not 
to any great extent, and necrosis of the nasal bones and hard 
palate is rare. 

The affection of the nares is prone to extend posteriorly 
into the faucial and laryngeal regions, producing mucous tuber- 
cles and a thickening of the mucous membrane about the epi- 
glottis. Alopecia is usual, embracing not only the scalp, but 
also the eyebrows and tarsal appendages. The earlier the 
symptoms are manifested in an infected child, the more severe 
is the disease. When the symptoms are clearly apparent at 
birth, the case commonly proves fatal before many days. 
Among the earliest symptoms of syphilis is obstinate wakeful- 
ness at night. The child may be tolerably quiet during the 
day, but as night approaches it becomes peevish and fretful and 
cannot be induced to sleep except in fitful naps, from which it 
wakens with a start or scream. It is supposed that this rest- 
lessness is excited by nocturnal pains in the bones, similar to 
those affecting adults. 

Diagjiosis. — The diagnosis of hereditary syphilis is not usu- 
ally attended with much difficulty, although in some cases it 
may be. The absence of a rash cannot be considered decisive 
evidence either for or against it. A true syphilitic rash is, at 
times, so slight in extent and mild in character, as to attract no 
attention, or it may simulate the rash of one of the eruptive 
fevers, especially of roseola, so closely as to breed confusion. 
When the rash appears on the soles and the palms, it has spe- 
cial significance. Chronic snuffling is one of the most reliable 
signs. If snuffles appear soon after birth, and continue for 
weeks or months, the fact is highly suspicious. Collapse of 
the bridge of the nose, when present, is another valuable sign. 
Enlargement of the spleen, with a tendency to marasmus and 
without having had previous digestive trouble, is also a strong 
count in the indictment. 

Prognosis. — This is always uncertain if it be not grave, but it 
becomes less serious the later the appearance of active symp- 
toms. The severity of the nasal symptoms is usually an index 
of the severity of the disease, and complicates its nature. If 
they are of such a character as to interfere with respiration and 
nutrition, they are pretty sure to produce, sooner or later, ex- 
haustion and death. The degree of splenic enlargement has a 
strong bearing upon the prognosis in syphilis. The majority 
of cases die, wherein the spleen is greatly enlarged. 

When the infant survives, he may apparently throw off 
all traces of the disease, and grow up a strong and healthy 



270 THE DISEASES OF CHILDREN. 

adult. But when the symptoms have been severe, more or 
less permanent impression is left upon the constitution and 
various vicissitudes constantly menace the progress towards 
maturity. 

Treatment. — There is but one remedy for syphilis, whether 
in child or adult, and when that fails, hope may as well be 
abandoned. 

That remedy is mercurius. The marked analogy between 
the syphilitic cachexia and the toxic effects of mercury, are so 
obvious as to render the curative relation of the latter to the 
former a foregone conclusion to any disciple of our professional 
dogma, similia, siinilibus curantur. No other drug in the ma- 
teria medica will produce the same train of symptoms from the 
most trivial and superficial, to those which are lasting and deep- 
rooted ; and no other remedy bears any comparison to it for 
direct curative power when judiciously administered. The 
abuse of mercury by the old school should not be allowed to 
weigh against its use in cases where it is so manifestly applica- 
ble, and wherein the universal experience shows that for it, we 
have no analogue. 

As to the particular preparation of mercury, giving the best 
therapeutic results, there may be a diversity of opinion. The 
strong tendency to ganglionic involvement, with nutrient fail- 
ure, in syphilitic infants would seem to point to mercurius bin- 
iodide, as the one most applicable, and our own experience is 
confirmatory of the theory. 

It should be given in grain doses of the third decimal tritura- 
tion every four to six hours, until improvement is noticeable, 
and then the interval between doses should be extended to ten 
or twelve hours. 

Old-school authorities recommend the introduction of mer- 
cury into the system by means of inunction, and as they have 
many things to learn of us, we need not hesitate to learn from 
them. 

Dr. Alfred Post says : " One of the most satisfactory methods 
of treatment is inunction by means of mercurial ointment, 
diluted with an equal quantity of petrolatum. With this oint- 
ment, a piece of cloth large enough to cover in great measure 
the child's abdomen, is thickly spread and placed under the 
flannel bandage. It is renewed daily, and its position may be 
shifted from front to back, or side as often as any sign of irrita- 
tion appears, or regularly so as to forestall any irritation. The 
movements of the child serve to keep up a slight friction, which 
is sufficient to introduce the mercurial into the economy. The 
application of the ointment by actually rubbing the skin with a 
ball of cotton or a swab covered by the mercurial is sometimes 



INFANTILE Sl^PHILIS— TREATMENT. 271 

advised, but is a less satisfactory method than the constant 
application." 

The nutrition of syphilitic infants requires attention. If it 
is possible, the child should be wet-nursed, but the employment 
of a healthy wet-nurse for a syphilitic infant, or even for one 
suspected of being syphilitic, is not justifiable. 

In case the mother is apparently healthy, though her child is 
syphilitic, the child should continue to be suckled by its mother. 
There is no reason to fear that the child will injure its mother 
by so doing, in accordance with the facts known as Colles's law. 

This law briefly stated is as follows : Women who are not 
syphilitic themselves, but mothers of syphilitic children, born 
of syphilitic fathers, possess an immunity as regards liability to 
contract syphilis from the act of suckling. 

This fact, which has been enunciated into a law, was brought 
into special prominence by Mr. Colles of Dublin, who averred 
that he had never seen or heard of a single instance in which a 
syphilitic, breast-fed child, deriving its infection of syphilis from 
its parents, had caused an ulceration of the mother's breasts, 
whereas, very few instances have occurred where a syphilitic 
infant has not infected a strange hired wet-nurse, who had been 
previously in good health.* In cases where the mother is her- 
self infected as well as the child, especially if her disease was 
contracted shortly before or soon after conception, she should 
not attempt to nurse the infant, for the reason that her milk 
would be almost certain, as a result of the disease, to lack the 
essential nutritive properties for the needs of the child. It 
should be placed upon a suitable artificial food, although the 
chances of its survival are thereby less than they would be if 
suckled by a healthy wet-nurse. 



" Practical Observations on the Venereal Diseases," 1837, P- 285. 



PA RT V. 

THE ERUPTIVE FEVERS. 



CHAPTER I. 

GENERAL CONSIDERATIONS. 

The eruptive fevers include measles, scarlet fever, rotheln, 
roseola and varicella. By some authors variola, or small-pox 
is included in the list, but we think without reason, and it 
is here omitted, because it is not in any sense an infantile 
disease ; and when it does occur in early life, it has no features 
or peculiarities which it does not possess when afflicting adults. 
These fevers are sometimes called the exantJiemata, on account 
of the efflorescence accompanying them ; and they are also 
sometimes called the zymotic diseases, or were so called when 
all eruptive diseases were supposed to be caused by a fer- 
ment, " leaven." They are of surpassing interest to the 
pathologist, as well as to the medical student and practi- 
tioner, because of their mysterious origin, their widespread 
prevalence and their peculiar character. They differ from other 
forms of acute illnesses, by being always accompanied — when 
given normal expression — with an extensive and characteristic 
eruption or rash, which appears at a tolerably regular stage of 
the disease, remains visible for a certain number of days and 
disappears, leaving the cutaneous epithelium more or less dead 
and scaly. They have so many characteristics in common, 
that they may conveniently be studied as a whole before point- 
ing out their individual peculiarities. 

They are all diseases of early life, and when adults are affected 
by them, as they sometimes are, it is the exception and not the 
rule. 

They are thoroughly democratic in their proclivities, visiting 
the rich and poor alike, and making no discrimination as to sex 
or color. 

They are universally distributed over the inhabited world, no 
nation or people, so far as known, being exempt from their 
ravages. They all incline to appear at times in an epidemic 
(272) 



THE ERUPTIVE FEVERS. 273 

form, in which case they attack children, who have not been 
previously affected, over wide areas of country. 

They rarely affect individuals more than once, and these 
individuals thereafter enjoy a complete exemption from further 
attacks, no matter how much or often they come in con- 
tact with them. None of these diseases, however, affords pro- 
tection from the others. All of them are contagious — some 
only mildly so — and some of them are both contagious and 
infectious. All of them are attended by more or less fever, 
and all of them are accompanied by a rash which is peculiar to 
itself. All of them have a period of incubation, or a period of 
latency following exposure, during which there are no symp- 
toms of ill health, and it is not until after this period of incuba- 
tion, which differs in duration with the different diseases, that 
the peculiar characteristics of the affection show themselves 
and render it possible to make a differential diagnosis. Most 
of them are followed by certain constitutional effects in many 
cases, which are so constant as to be called seqiielce. All of 
them are varied or modified more or less by the year, the age, 
constitution, etc., etc. 

Formerly all of these eruptive diseases were considered and 
treated as modifications of one contagion, viz., variola. In 
certain epidemics of the eruptive fevers, cases occur which par- 
take so much of the characteristics of two diseases, that a diag- 
nosis is very puzzling. This is particularly true of scarlatina 
and measles. 

We have seen cases of measles without prodroma and with a 
sore throat, and in which the rash was so nearly confluent as to 
be readily mistaken for scarlatina. 

Rotheln and measles are so closely related that a severe case 
of the one is almost indistinguishable from a mild case of the 
other. 

As a rule, however, each one of these affections has its dis- 
tinctive features that render it easily recognizable. They are 
all self-limited in duration. 

The etiology of the eruptive fevers is very uncertain. Their 
contagiousness is everywhere recognized. The contagion of 
one of them — scarlet fever — has such vitality that it is believed 
to retain its infectious properties for many years. The conta- 
gium of measles is only mildly infectious. Epidemic influence 
is undoubtedly most largely responsible for the perpetuity of 
these affections. 

In large cities they are endemic. In New York and Chicago 

there is no month of the year when scarlet fever and measles 

are not mentioned in the mortality reports. In the transitional 

periods, spring and fall, they are always more prevalent, doubt- 

D. C— 18 



274 THE DISEASES OF CHILDREN. 

less for the reason that at such times colds are numerous, and 
the resistant powers of the system against miasmas is thereby- 
lowered. 

The occurrence of isolated cases of these eruptive fevers has 
always been a puzzling phenomenon. 

That apparently sporadic cases do occur, is a matter of fre- 
quent observation. The prolonged vitality of the scarlet-fever 
poison has been frequently demonstrated ; and it is believed 
that the poison is so subtile and transmissible, that it may be 
conveyed long distances in articles of merchandise, ** even in 
small packages, so that those who chance to open them or 
come in contact with them, are infected. It is believed that 
reading-matter, transmitted through the mails, has in many 
instances been the medium of infection."* 

That a contagious principle does exist, by means of which 
these different diseases are disseminated among communities,, 
affecting now individuals, and again producing widespread 
epidemics, is clearly shown in the very admirable article on this 
subject by Dr. West. 

He says : *' Facts, such as the absence of measles for the 
period of thirty years from the Cape of Good Hope, and its 
development after the arrival there of a vessel from Europe, in 
which several cases had occurred during the voyage, substan- 
tiate the correctness of this opinion. The strongest proof of 
it, however, is afforded by the circumstances in which measles 
prevailed in the Feroe Islands, in 1846, after an interval of 
sixty-five years. They were then introduced into one of the 
islands by a workman, who leaving Copenhagen on March 20th, 
reached the Feroe Islands on the 28th, apparently in good 
health, but fell ill with measles on April ist. His two most 
intimate friends were next attacked, and from that time the 
disease could be traced from hamlet to hamlet, and from island 
to island, until 6,000, out of a total population of 7,782, had been 
attacked by it ; age bringing with it no immunity from the 
contagion, though the disease was found to spare all who in 
their childhood had suffered from it at the time of the previous 
epidemic." 

The closer commercial relationship of to-day, between all 
countries, which includes even the most remote islands of 
the sea, makes a similar observation now impossible. It renders 
such a fact as this all the more interesting, and places it in the 
same category of unique observations as those afforded by the 
fenestrated stomach of Alexis St. Martin, for the study of gas- 
tric digestion. It shows that these eruptive fevers are only 



♦J. L. Smith. 



THE ERUPTIVE FEVERS. 275 

peculiar to infancy and childhood, because few children reach 
maturity without having had them, and not because there is in 
early life any special or peculiar susceptibility to their influence. 
At least, it shows that this is the case with measles, and renders 
it extremely probable that the other affections of an eruptive 
and contagious character are so also. 

All that can be said at the present day with regard to the 
etiology of these diseases, is, that each is produced by and gives 
rise to a subtle and destructive poison of variable intensity and 
tenacity, which tends to perpetuate itself by affecting suscepti- 
ble persons, who may in turn communicate it to others through 
various media, such as the bodily excretions and emanations, 
and by contact and fomites — the latter being, in the judgment 
of many, the chief source of epidemics. 



CHAPTER II. 

MEASLES (rubeola ; MORBILLi). 

Definition. — Measles is the most contagious of all the exan- 
thems. It affects the vast majority of mankind in all civilized 
countries. It is an acute contagious and epidemic disease, 
commencing with all the usual symptoms of a catarrhal cold, 
having a characteristic rash which lasts from three to five days, 
and terminates with a mild desquamation. It is strongly epi- 
demic in its tendency, so that its frequency varies greatly at dif- 
ferent times. It attacks a far larger number of people than scarlet 
fever, but the mortality resulting from it is very much less. It 
is equally prevalent in both sexes, and but rarely affects nursing 
infants under six months of age. 

Mode of Infection. — The contagious principle is most active 
during the catarrhal stage, and continues in a less active form 
through the stage of desquamation. It may be carried in fom- 
ites, but not so generally as scarlet fever. 

The stage of incubation is variable, lasting from five or six 
to twenty days or longer, with an average of twelve. During 
this period there is nothing to indicate its presence, although 
most authorities believe that the disease commences to exert 
its influence in the system from the moment of infection, and 
that during the period of seeming latency, it is gathering force 
which finally breaks out into recognizable symptoms. The ac- 
tivity of the contagion during the catarrhal stage, when the 
symptoms are those of an ordinary cold, and the children so 
affected are not suspected to have measles, is one reason of its 
wide diffusion through communities. At this time, the cough, 
the breath and the mucous secretions are all infectious, and 
probably the emanations from the cutaneous surface also. 

Symptoms. — The disease is divided into four stages : first, the 
stage of incubation ; second, the prodromal, or stage of inva- 
sion ; third, the stage of eruption ; and fourth, the stage of de- 
cline or desquamation. 

Stage of Invasion. — At a period, which, as has already been 
stated, is variable, the rubeolous poison manifests itself ; first 
by a catarrhal inflammation of the mucous membrane of the 
respiratory organs. The symptoms at first are indistinguish- 
able from those accompanying an ordinary coryza. There may 
(276) 



ME A SLES—S TA GE OF ER UP TION, 277 

be shiverings, headache, loss of appetite, languor, and in young 
infants, convulsions. 

In the majority of cases these manifestations are exhibited 
in a mild degree only, and the symptoms are not so grave as to 
interfere with school or pastimes. There is more or less 
cough, at first dry and tight ; afterwards loose and rattling. As 
the disease progresses, these catarrhal symptoms become more 
pronounced. The mucous membrane of the eyes, nose, throat, 
larynx, trachea and bronchial tubes becomes involved. Frequent 
sneezing and cough are nearly always present. The conjunc- 
tivas become reddened and congested, and there is more or 
less photophobia with lachrymation. The discharge from the 
nasal passages, which are inflamed and swollen, is at first thin 
and watery, but soon becomes abundant, thick and muco-puru- 
lent in character. 

Sometimes the cough becomes croupy, and the swelling of 
the mucous membrane of the larynx causes embarrassment of 
respiration. In rare and exceptional cases edema of the glottis 
occurs, and constitutes a dangerous complication. 

Nausea and vomiting are often present, but occurring in this 
stage of the disease, do not, as a rule, constitute alarming symp- 
toms. Sometimes there is epistaxis. 

The intensity of the disease varies greatly in different epi- 
demics, and the severity of the attacks and their complications 
depend to a considerable extent on age, constitution, hygienic 
conditions, season of the year, and previous state of health. 
Sporadic or isolated cases are usually milder than when the 
disease is prevailing in epidemic form. 

The fever which accompanies this stage is usually not 
intense, and in very mild cases may be altogether absent. 

In severe cases the temperature may go as high as 102°, or 
even 104° Fahr. 

Stage of Eruption. — On the third or fourth day after the 
catarrhal symptoms first manifest themselves, the eruption 
appears, showing itself first on the forehead, temples and 
cheeks, and soon extending to the face, breast, trunk and ex- 
tremities. From twenty-four to thirty-six hours are occupied 
in the development and extension of the eruptive process. The 
eruption at first appears in the form of minute red spots, 
resembling flea-bites, and are coarsely scattered over the sur- 
face, but they rapidly increase in size and number and become 
distinctly papular, with the papules flattened on top. If the 
tips of the fingers are passed over the surface, the latter feels 
uneven and rough. The papules incline to coalesce in the form 
of a half-circle or crescent, and are of a deep red or purplish 
color. Between the spots, in many places, are small areas of 



278 THE DISEASES OF CHILDREN. 

skin of normal color. The confluence of the papules, which is 
more marked on the face, neck and forearms, gives to these 
portions of the body a peculiar blotched and swollen appear- 
ance. By the end of the second day of the eruption and the 
sixth day of the disease, the latter is at its height. By this time 
the eruption has extended to all parts of the body, but is more 
marked in some portions than in others. The fever does not 
abate on the appearance of the eruption ; both it and the cough, 
which were present during the stage of invasion, continue with- 
out change, and remain so during the subsequent two days, at 
which time the eruption begins to fade, the fever diminishes, 
and the catarrhal symptoms decrease. The bowels are usually 
constipated in the outset, but as the eruption subsides diarrhea 
is very apt to show itself. 

Enlargement of the cervical and submaxillary glands is not 
uncommon. The tongue is lightly coated throughout the dis- 
ease, but remains moist. After the eruption has lasted about 
four days, or on about the eighth day of the malady, all of 
the symptoms above described moderate, save one, and the 
fourth or last stage is reached. The onty one of the symptoms 
to persist is the cough. The cough, which, as we have seen, 
was the first symptom to appear, is the last one to disappear. 
It sometimes continues for some weeks after all other symp- 
toms have subsided. After the eruption has faded from the 
surface, it may still be seen for a number of days underneath 
the skin, to which it gives a peculiar mottled appearance. 

If the child becomes overheated from any cause, this mottling 
shows very plainly. Notwithstanding this, and in spite of the 
persistent cough, the patient rapidly regains appetite and spirits 
and is soon in ordinary health. The stage of decline is marked 
by a fine desquamation of the cuticle, which continues sometimes 
for several weeks, but is not so extensive and apparent as is 
observed in scarlet fever. It is usually greatest where the 
eruption was most intense. 

Irregular or Atypical Measles. — We have described 
measles as it appears in its usual or typical form. But it does 
not always pursue this regular course, and like all of the other 
eruptive diseases, is occasionally seen lacking some one or more 
of its ordinary symptoms. Thus, we have exceptional cases 
now and then, where there is a distinct history of exposure to 
the contagium of measles, and in due time an illness, which is 
unmistakably due to this exposure, but in which there is a 
marked variation from the ordinary run of symptoms. We 
may meet with cases in which the catarrhal symptoms are ab- 
sent, or present in so slight a degree that the disease is termed 



IRREGULAR OR ATl'PICAL MEASLES. 279 

morbilli sine catarrJio. In such cases the eruption occurs with- 
out premonitory symptoms, and with this exception, the malady 
is attended with the ordinary phenomena. There are other 
cases in which the catarrhal symptoms are well expressed, but 
the eruption is scanty or entirely absent. Such cases are styled 
morbilli sme cxantJicmati. Again, there are cases where the 
eruption remains on the surface for an unusual period, or where 
it is much darker and thicker than common. 

In the latter case, the disease is termed black or vialignant 
measles. Here the eruption is confluent, and there is extrava- 
sation of blood with great depression of the vital forces. The 
temperature runs very high, the pulse becomes very rapid and 
feeble, the extremities are cold, and the patient may speedily 
drift into convulsions or coma. This type of measles is very 
fatal, and death may ensue before the eruption has been fully 
established. It occurs most frequently in cachectic subjects, 
whose constitutions are more or less racked or broken by pre- 
vious illnesses, or in crow^ded tenements where the surround- 
ings are peculiarly bad. 

Complications. — The course of measles is very apt to be com- 
plicated with some other affection w^hich is usually an inflam- 
mation of some portion of the mucous membrane, either of the 
respiratory or alimentary tract. 

In measles, the mucous membrane is always involved, more 
or less, and the inflammation only constitutes a complication, 
when so intensified as to give rise to grave or dangerous symp- 
toms. Diphtheritic inflammation of the fauces sometimes 
occurs, and is a serious complication, especially w^hen it extends 
into the larynx. 

Stomatitis, of varying severity, is a common attendant on 
measles, especially in the very young, and gangrene of the 
mouth may occur as a complication or as a sequela. 

When conjunctivitis is attended with a purulent discharge, 
which threatens the cornea, it is to be regarded as a complica- 
tion. Inflammation of the pharynx may extend up the eu- 
stachian tube, and involve the middle ear, producing otalgia, 
catarrhal inflammation or deafness. 

Enteritis is a very common complication, and is apt to run a 
protracted and dangerous course. 

The most common and most serious of the complications of 
measles, are capillary bronchitis and pneumonia. 

If, on the seventh or eighth day, when the febrile symptoms 
ought to abate, there should be an elevation of temperature, 
w^ith the face swollen and the lips dry ; if there be present an 
increased frequency of respirations and pulse ; w^andering or 
delirium during sleep, and especially if auscultation reveals fine 



280 THE DISEASES OF CHILDREN. 

crepitant or subcrepitant rales, we may feel sure that we have 
catarrhal pneumonia or capillary bronchitis to deal with as a 
complication. As will be seen in a succeeding chapter, these 
two affections are practically one and the same thing — a dis- 
tinction without a difference. Lobar pneumonia will present 
pretty much the same train of symptoms, with the exception 
that the dyspnea is not so great, while the dullness on percus- 
sion is greater. 

Carditis and rheumatism are not uncommon as either com- 
plications or sequelae. 

Diagnosis. — It is usually difficult, during the stage of inva- 
sion, to discriminate between measles and an attack of coryza 
or bronchial catarrh. The history of the case, if it points to an 
exposure to measles, may help to the formation of an opinion ; 
but otherwise the diagnosis must remain uncertain until the 
characteristic eruption appears. Even then, the disease may 
be confounded with some one or other of the exanthems, such 
as rotheln, scarlet fever, variola, varicella or typhoid fever. 

A careful study of the characteristics of each of these dis- 
eases will generally be sufficient to make a diagnosis clear. It 
is best, however, in many cases, to reserve a positive opinion 
until the symptoms have had time to completely declare them- 
selves, meanwhile exercising proper care to protect other indi- 
viduals from exposure, who have not had all of the exanthems 
previously. 

The disease with which measles has been most frequently 
confused is probably variola. In the latter disease we fre- 
quently have catarrhal symptoms, though usually less marked 
than in measles. During the first twenty-four hours, the two 
eruptions are very similar in appearance, but in a few hours 
more, the eruption in variola becomes beady and the papules 
have a distinct elevation, which is perceptible to the touch 
when the hand is passed over the surface. Besides this, in va- 
riola the active symptoms abate as soon as the eruption declares 
itself; the pain in the back, the fever, the headache, all disap- 
pear; while in measles, the fever and all of the acute symptoms 
continue without change. 

In measles, the eruption remains papular throughout its 
course and never becomes vesicular, while in variola, the pap- 
ules soon become vesicles, and then pustules. 

In typhoid fever we have an entire absence of catarrhal symp- 
toms, and the petechial eruption peculiar to it, and which 
sometimes slightly resembles that of measles, does not appear 
until the seventh day, while in the latter disease it appears on 
the fourth day. 

SequelcE. — It is a very common thing to hear of some chronic 



IRREGULAR OR ATYPICAL MEASLES. 281 

derangement in patients we are called to treat, as dating from 
an attack of measles. Otorrhea, strumous ophthalmia, en- 
largement or suppuration of the cervical glands, chronic diar- 
rhea, croup, tabes mesenterica, are all recognized as liable to 
follow in the wake of measles. But they are complications 
that are largely avoidable by proper care and attention during 
the course of the disease and during convalescence. 

It is never safe for a child, who has suffered from any of the 
eruptive fevers, to be exposed to cold or dampness until several 
weeks have elapsed after all signs of the disease have vanished. 
Among the sequelae of v[\Qdis\&s, phthisis pulmo?ia lis n\ust not be 
forgotten. Among all the eruptive fevers, there is none so 
prone to fire up a latent dyscrasia as measles. A child of deli- 
cate organization, in whom there has been a suspicion of struma, 
should be watched with the greatest care while passing through, 
or convalescing from, this disease. The greatest danger is 
during convalescence. An irregular thermometry, after the 
eruption has faded, should be regarded with grave suspicion 
and frequent opportunity should be utilized in making a careful 
examination of the lungs, in order to detect the first evidences 
of breaking down of the lung structure. 

In cases where there has been considerable bronchitis or 
pneumonia, the diagnosis of incipient phthisis will usually be 
attended with difficulty ; but the dangerous tendency of the 
disease should be remembered and every care taken to avoid 
surprise. 

Prognosis. — In general, the prognosis in measles is good. In 
private practice, when the surroundings are wholesome and the 
child can have good care, and when the disease occurs in a 
patient of fairly good constitution, there is little danger to be 
feared ; but in children of a strumous habit, or whose system is 
broken down by a previous disease, as whooping cough or 
malaria, the disease is not infrequently attended with a fatal 
issue. Sometimes during epidemics of measles, a strong and 
healthy child will be attacked by the disease in a malignant 
form, and will perish in spite of every care and attention. 

In crowded tenements, where but little care of an intelligent 
kind is given to the sick, and where every sanitary law is vio- 
lated, measles is a very serious and fatal malady. So too, in 
camps where patients are exposed to the vicissitudes of the 
weather, the disease is attended with alarming fatality. The 
African race does not endure the disease well. The writer had 
an extensive experience with colored people while in the hos- 
pital at New Orleans, during the war of the rebellion, and found 
that measles was nearly, or quite, as fatal among them as 
variola is among the whites. They contract bronchitis or pneu- 



282 THE DISEASES OF CHILDREN. 

monia very readih^ probably owing to exposure and a lack of 
care. 

The prognosis is favorable in cases that run an even and reg- 
ular course, and is grave or serious if complications intervene, 
such as bronchitis, pneumonia, diphtheria or laryngitis. Entero- 
colitis and dysentery also add to the danger, but do not always, 
by any means, portend a fatal issue. The continuance of fever 
after the disappearance of the eruption always indicates a com- 
plication, and should suggest a reserved prognosis. The occur- 
rence of convulsions, if at the beginning of the eruption or 
during the premonitory stage, is not a complication of any 
great moment. It does not commonly indicate unusual sever- 
ity or serious complication. When convulsions occur later 
in the progress of the disease, however, they nearly always 
point to a fatal termination. 

Treatmeyit. — The disease being self-limited in duration and 
non-preventable, when once the contagium has been encount- 
ered by a susceptible subject, there is little need of treatment 
when it runs a benign course, in a person otherwise healthy. 
It is only in cachectic individuals, whose systems are debilitated, 
or when the natural course of the malady is modified or inten- 
sified by what are denominated *' complications," that drugs 
are either useful or necessary, In cases, however, where the 
pyrexia is high and attended by restlessness, aconite may be 
given. If convulsions threaten, gelsemitim, cuprum, veratruvi 
vir., ox passiflora may afford relief ; if cephalalgia is intense, bell.; 
if eruption is delayed, or only partial, bryonia. For the char- 
acteristic cough, which is nearly always troublesome, there is no 
remedy of equal value with Pulsatilla. This drug is also useful 
in developing the eruption, and in controlling the irregular ten- 
dencies of the disease, should they be present. For the ordinary 
diarrhea, which is commonly present at some stage of the dis- 
ease, no remedies are needed. It should be allowed to pursue 
its course unless excessive in duration or frequency. In the 
latter case ipecac, aloes, mercurius or nux vomica may be called 
for. If the diarrhea becomes dysenteric, the usual remedies 
described under that head should be given. If the cough does 
not respond to pulsatilla, but becomes dry and tight, givQ phos- 
phorus or tartar emetic. 

The throat affections and those pertaining to the eye and 
ear should be treated just as the same affections would be if 
occurring idiopathically. 

In ordinary cases the treatment required will be more hygienic 
than medicinal. The temperature of the sick room should be 
maintained at nearly as possible at &^^ Fahr. It should not be 
allowed to go below 65° Fahr. nor above 70° Fahr. 



IRREGULAR OR ATYPICAL MEASLES. 



283 



If the temperature of the body exceeds 103° or 104° Fahr., 
there is no possible injury that can result from a tepid sponge 
bath. The diet should be bland and simple, and adapted to the 
age of the patient and the condition of the stomach. 

Cooling drinks are perfectly permissible and may be acidu- 
lated if desired. 

The danger from bronchitis and pneumonia should be con- 
stantly borne in mind, and suitable precaution taken to avoid 
them. The danger from these sources is not over until conva- 
lescence is fully established, and the patient should be restricted 
to the house for at least three or four weeks after the eruption 
has entirely subsided. 

The following table of mortality from measles shows the 
relative frequency of the disease in this city for eight years. 

Comparative Mortality of Measles in the City of Chicago (of 

Children Under 5 Years of age) by Quarters, for Eight 

Years, commencing at 1885, with Yearly Totals. 



Quarters, 


18S5. 


1SS6. 


1SS7. 


18SS. 


1889. 


1890. 


1891. 


1892, 


Total 
for the 
eight 
years. 


Winter 

Spring 

Summer 

Autumn 


20 

28 

1 


13 

28 

34 


145 
149 

38 

9 


9 
40 

52 

50 


96 

77 

25 

6 


5 

17 
12 

38 


102 
102 

41 
20 


22 
37 
41 
85 


412 

478 
284 
246 


Totals by yrs. 


76 


126 


341 


151 


204 


72 


265 


185 


1420 



CHAPTER III. 

ROTHELN (GERMAN MEASLES; RUBELLA; FRENCH 
MEASLES). 

Definition and History. — Besides the synonyms given above, 
this disease is blessed with many more. It is called by some, 
hybrid, false or bastard measles ; roseola ; morbilli sine catarrho ; 
and it is known also by many other appellations, which are 
needless to mention. This multiplicity of names, which would 
be enough to embarrass a prince royal, is not due either to 
the gravity or the dignity of the disease, but to the uncer- 
tainty which still exists as to its true nature and origin. So 
late as 1865, it was by many believed to be a variety of measles. 
By others, it was thought to be a hybrid partaking of the nature 
of both measles and scarlet fever. Others, again, considered 
it a modified form of one or the other of these diseases, but 
were uncertain as to which it was most closely related. The 
consensus of opinion now is, that it is sui generis: a distinct 
disease by itself, and in no way related to either measles or 
scarlatina. 

This opinion is based upon the fact — which recent opportuni- 
ties for study have demonstrated — that epidemics of rotheln 
prevail without any regard to the existence of cases or epidem- 
ics of either measles or scarlet fever, and that it occurs in per- 
sons who have previously had both of these diseases. It is 
altogether probable, in cases of which we hear or used to hear 
so often, of measles or scarlatina being repeated in the same 
individual, that one of the attacks was mistaken for the affec- 
tion under consideration. 

As understood at the present day, rotheln or rubella may 
be defined to be a specific, epidemic and contagious eruptive 
fever, at times closely resembling measles, and at other times 
more closely resembling scarlatina, but having an individuality 
of its own, with peculiar characteristics, which distinguish it 
from both these diseases. It is a disease to which children are 
mostly susceptible and one attack of it usually protects the 
individual from a subsequent invasion. Its most marked pe- 
culiarity is a prodromal enlargement and induration of the cer- 
vical glands, without tendency to suppuration. 

Hitherto the cases which have been seen personally by the 
(284) 



ROTIIELN. 285 

writer, have been so mild and so devoid of complications and 
sequelae as to give him the impression that the disease was un- 
worthy of more attention or comment than would be a similar 
number of cases of mild rubeola. Even the recognized impli- 
cation of the cervical glands, has been transient and unobtrusive, 
and he has never seen a case where the attendant symptoms 
were in any sense alarming or even serious. In the spring of 
1892, we had quite an epidemic of rotheln in Chicago, and there 
was ample opportunity to observe its symptoms and course ; 
but all of the cases in the writer's practice were so mild that 
but one or two visits were made to them and no notes were 
taken of them. In a few of the cases the diagnosis was in doubt 
for a day or two, owning to the close resemblance to either mea- 
sles or scarlet fever, but as a rule, the cases were pretty clearly 
defined. There were no fatal cases, nor were any of them 
attended with either sequelae or complications. 

Dr. William A. Edwards,* who has made an exhaustive study 
of the disease and seems to have had a very large acquaintance 
with it, both in hospital and private practice, says that in his 
experience the mortality is from four to five per cent., and that 
this death rate is largely due to complications. He also states 
that the disease is more prone to be epidemic than any of the 
other exanthems, and a strong tendency to relapse is noted, in 
which cases, the " disease may manifest itself with all its pri- 
mary vigor, or it may be attended by a lesser degree of intensity 
of all the symptoms, particularly the prodromal." 

As an illustration of the uncertain and ill-defined character 
of the disease. Dr. Edwards states that the prodromal symp- 
toms last ''from a few hours to a week," and various authorities 
are cited who state that the eruption appears first on the face 
and neck; that it is usually seen first on the back and chest, on 
the breast and arms ; while others are equally firm in the opin- 
ion that "it comes out all over the body at once." 

According to Dr. Edwards, the disease is equally versatile in 
the color and character of the eruption. '' In my own cases," 
he says, " the rash was multiform in character, more or less con- 
fluent, occasionally ill-defined, in color rosy or pale red. A few 
cases of the brightest scarlet and some purplish tints were ob- 
served. The rash was punctated ; small macules were noted ; 
over the more vascular parts, the rash was sometimes elevated, 
producing a rough skin easily detected by the touch. The 
patches were very irregular in outline, shape and size, the last 
factor being the most irregular. The center of each patch was 
much higher in color than any other part. . . . The total 



" Keating's Cyclopedia of Diseases of Children," vol. i, page 684 et seq. 



286 THE DISEASES OF CHILDREN. 

duration of the rash is much influenced by the character and 
type of the epidemic, and has been variously reported by differ- 
ent observers. The average duration in over two hundred 
cases of my own, was five days. In this series, the shortest was 
scarcely two days, and the longest of all the cases was fifteen. 
. . . Sore throat was always present in my cases, and en- 
largement of the tonsils to a great extent. Many of the cases 
also presented marked pharyngitis and dysphagia. 

"• Enlargement and induration of the cervical, post cervical and 
post auricular glands, were present during the eruptive stage ; 
occasionally only one or two were affected, in other cases the 
entire chain. This we may consider one of the most diagnos- 
tic signs of the disease." 

Diag7tosis. — From what has been said, it is evident that a 
disease which holds so loosely to a type as this ; that shows 
itself so differently at different times to the same observer, and 
is described so differently by various authorities, must be at 
times very difficult to diagnose. It is apparent that the disease 
often presents symptoms very closely resembling measles, and 
again very like scarlatina. In severe cases the complaint is 
ushered in with shivering and febrile disturbance, headache, 
pains in the limbs, sore throat, redness of the pharynx and 
tonsils, and in some instances nausea and even vomiting. In 
addition to these symptoms, there is catarrh, cough, sneezing 
and coryza. All of these symptoms are like those of measles. 
But there are cases where the swelling of the throat and tonsils 
and the white, coated tongue, followed by redness and raised 
papillae, show a remarkable likeness to scarlet fever. But the 
premonitory fever and coryza, instead of lasting three or four 
days as in common measles, seldom lasts more than twenty- 
four hours before the rash makes its appearance. The temper- 
ature, even in severe cases, does not range as high as in either 
measles or scarlatina. In the latter disease the nausea and 
vomiting are common, in rotheln occasional only. In rotheln, 
swelling of the cervical glands is nearly, or quite universal ; in 
scarlet fever, occasional only. 

The diagnosis of rotheln is aided somewhat by its strongly 
marked epidemic character. Isolated cases of it are rare. This is 
not true, to the same extent at least, of scarlet fever. In my 
own experience, the eruption of rotheln is more scattered and 
more of a rose color than measles, and not nearly so likely to be- 
come confluent. 

All of the symptoms are of mild type, as compared with the 
diseases which it so closely resembles. The mild character of 
the attack ; the swelling of the cervical glands ; the more rapid 
progress of the disease from stage to stage ; its presence in 



ROTHELN. 287 

epidemics rather than in sporadic form, are generally sufficient 
to make a diagnosis fairly easy, except in rare instances. 

The following letter from Dr. Hedges, who has had a very large 
experience at the Chicago Half Orphan Asylum, extending 
over a great many years, is inserted here, in order to give em- 
phasis to what has already been said. 

My Dear Dr. Tooker — In reply to your questions as to rotheln 
would say — 

(i) Have never had a fatal case. 

(2) Have recently had a serious case — do not remember another. 

(3) The enlargement of post-cervical glands has lasted for sometimes a 
week or ten days ; quite obstinate, and relieved by calc. iod. 

(4) The only pathognomonic symptom I depend upon is the enlarge- 
ment of the post-cervical and sub-occipital glands. This occurs early in the 
disease, often becoming a real adenitis ; otherwise the slight or absent 
catarrhal symptoms, paleness or brownness of eruption, and low fever, ab- 
sence of cough, generally outlined the case, and decided the diagnosis in 
my mind. 

Hope these few notes may be of some service to you. Will say in closing 
that it took an observation and experience oi years to enable me to feel sure 
that "German measles" was anything at all difTerent from measles 
(rubeola). So many times we are told, "My child has had j/i eas les, a.nd 
how can he have them again? " The presence of a distinct and different 
exanthematous disease from measles and very much like it will explain 
the cases where they have had it twice. 

Fraternally, S. P. Hedges 

From an interesting paper by Dr. Charles W. Townsend, of 
Boston, in the Archives of Pediatrics^ April, 1890, we extract 
the following conclusions: 

(i) Epidemics of measles occur in which many of the cases exactly re- 
semble cases described as rotheln. 

(2) That these cases are also found occasionally in severe epidemics of 
measles. 

(3) Thatglandular swellings and sore throat are sometimes found in cases 
of undoubted measles, and are sometimes absent in cases called rotheln. 

f 4) That the symptomology of rotheln is not distinct from that of measles. 

(5) That it is therefore impossible to make a diagnosis of rotheln from a 
single case. 

(6) Thatthe only ground on which the individuality of rotheln rests, is the 
fact that previous attacks of measles afford no protection from this disease. 

(7) That as second attacks of measles do occasionally occur, we cannot, 
from our present knowledge, make the diagnosis of rotheln, unless — as in 
the charterhouse and asylum epidemics — we meet with a series of cases in 
patients, many or most of whom have previously had measles. 

(8) That the impossibility of knowing how many second attacks may 
occur in a given epidemic of measles makes this proof of the separate exist- 
ence of rotheln somewhat problematical, and gives rise to the question, is it 
possible that in some epidemics, and not in others, a mild form of measles 
attacks equally those who have had measles before, and those who have not, 
and affords afterwards no protection from measles.'' In other words, is 
rotheln merely a mild form of measles.'' 



288 THE DISEASES OF CHILDREN. 

Treatment, — But little need be said under this head. Ordi- 
narily, the disease is so mild and innocent that only precautions 
need be taken to prevent suppression and avoid complications. 
The same hygienic measures may be observed as in measles. 
The remedies will have to be selected with reference to the 
symptoms as they appear. Severe cases may require close 
watchfulness and judicious medication, but ordinarily no medi- 
cine will be needed, and none should be given unless it is 
needed. The diet should be restricted to bland and unirritat- 
ing foods, and the bowels, if constipated, should be moved by 
enemata or suppositories. 



CHAPTER IV. 

SCARLATINA (sCARLET FEVER). 

Definitio7i. — Scarlatina is an acute, contagious and infectious 
disease, having a distinct and characteristic eruption, which is 
more or less diffused over the entire surface, and is accom- 
panied, in all cases, with fever and an angina of greater or less 
intensity. It is most prevalent between the ages of two and 
seven years, but no age is absolutely exempt. Infants are 
sometimes born with it and the aged sometimes die with it. 
Infants at the breast are rarely affected, although they may be 
in exceptional cases. It is strongly inclined to run an irregular 
course and is so often followed by sequelae, that its duration is 
always uncertain. Epidemics of scarlatina are very common, 
but its epidemic character is not so marked as either measles or 
rotheln. 

Individual susceptibility has much to do with its prevalence; 
and yet the infective poison has such vital tenacity and such 
diffusability that it may be carried to long distances by fom- 
ites, which may retain their contagious properties for months 
or even years. In the intensity of its virulence it is the most 
variable and uncertain of all the exanthems. In all but the 
mildest cases, the eruption is followed by desquamation of the 
cuticle. 

History. — According to Dr. Murchison, ''scarlatina" is said 
to have been the vernacular name for the disease on the shores of 
the Levant, and was first adopted in a medical work by Prosper 
Martianus, another Italian physician, who, about the middle of 
the sixteenth century, also described the disease as distinct from 
morbilli. Epidemics of scarlet fever were first described in 
England by Sydenham, in 1676, and about the same time in 
Scotland, by Sir Robert Sibbald, physician to Charles II. It 
is thought to have been brought to this country by means of 
European shipping, about the year 1735, and from that time it 
has kept pace with the westward progress of civilization until, 
at present, there are few, if any localities, in the United States, 
which it has not invaded. 

'Varieties. — There is no disease with definite characteristics, 
which holds to a type so loosely as scarlet fever. As a rule spo- 
D.C.— 19 (289) 



290 THE DISEASES OF CHILDREN. 

radic cases are mild, and even epidemics have occurred in which 
all of the cases were so uniformly mild that it seemed either to 
be losing its virulence, or that advanced methods of treatment 
had shorn it of its terrors. Thus Sydenham, who saw only 
mild cases, considered it an " ailment," and unworthy the name 
of a *' disease," and Dr. J. Lewis Smith mentions the case of a 
distinguished physician, of New York City, who treated a large 
number of cases in one of the hospitals without a single death, 
and a few months later lost his own son, who died of a virulent 
attack of the same malady. In many cases the disease itself 
seems to run a simple and typical course, and to be devoid of 
danger, when, just as convalescence is begun, or seems to be 
well established, some of its characteristic complications or 
sequele set in which at once change the prognosis from favora- 
ble to grave or hopeless. 

In other epidemics — and these are most common — many of 
the cases run a simple and discrete course, and terminate with- 
out serious sequele ; while side by side with such cases, there 
will be others of the gravest character, which either suddenly 
end in death or leave the patient with chronic ailments of seri- 
ous nature and portent. 

For these reasons it has been found expedient to describe 
the disease under different classifications, such as regular, irreg- 
ular and malignant. As this arrangement seems to be the 
most simple and plain, we shall adopt it and describe the pecu- 
liar features of the affection under these several headings. 

SYMPTOMS OF REGULAR FORM. 

The disease usually begins abruptly, attacking the child in the 
midst of perfect health. It rarely begins at night, or exhibits its 
initial symptoms during the hours of slumber. More often the 
victim sleeps as well as usual during the night preceding the 
attack, but arises in the morning at the usual time, with a feel- 
ing of nausea, which is speedily followed by vomiting or empty 
retching. A fever of greater or less intensity ensues, and the 
child feels profoundly ill. At this time a careful inspection of 
the fauces will generally discover an angina, and if the child is 
old enough to explain its symptoms, will complain of pain on 
swallowing. In severe cases, where the throat is principally 
affected, there is danger at this period of mistaking the disease 
for a simple angina or diphtheria. The fever, however, is usu- 
ally higher in scarlet fever than in either of these affections, 
while the vomiting is well-nigh pathognomonic. After a few 
hours — varying from three or four to eighteen or twenty-four — 
the characteristic eruption makes its appearance, first on the 



SCARLATINA; SCARLET FEVER. 291 

face, the forehead, the neck and breast and clavicles. About 
the mouth, the skin has a peculiar pallor, from the contracted 
capillaries. The eruption is fine, quite uniformly diffused over 
the affected surface, and is intensely scarlet in color. While at 
a distance the skin looks smooth and evenly affected, a close 
inspection shows it to be finely punctated, with here and there 
lines or small areas of normal color. From the face and neck 
the eruption quickly diffuses itself, so that within twenty-four 
hours, or sooner, it has extended itself over the entire body. 
The color is not equally intense, however, being most so over 
the back and buttocks, and on the inside of the thighs, where 
the hue is deeply scarlet. The rash disappears on pressure, 
but reappears as soon as the pressure is removed. If the finger 
be drawn along the back of a well-marked case, it will leave a 
white line in its wake, which quickly disappears as the redness 
returns. 

A tardy return of color under these circumstances indicates 
a sluggish capillary circulation, due generally to nervous de- 
pression, and is not a good symptom. It is so found in grave 
cases, where the eruption is dull or dusky in hue. In some 
cases the eruption reaches its maximum intensity during the 
second day, but in others not until the third or fourth day. 
During the eruptive stage, the skin is dry and sensitive as well 
as hot, and the countenance has a puffed and swollen appear- 
ance ; but this is not usually so marked as it is in measles. 
The tongue is generally coated from the beginning, but this 
coating becomes more thick and pasty as the disease progresses, 
until on the second or third day it melts away, leaving the red 
and swollen papillae standing up prominently over its surface, 
constituting the strawberry or mulberry tongue, which is one 
of the pathognomonic symptoms of the disease. This thick 
coating of the tongue and its papillary studding, its quick melt- 
ing away, like snow in springtime, leaving the raised and red 
papillae, is rarely if ever seen in any other disease, and is so char- 
acteristic as scarcely to elude notice. It should be said, how- 
ever, that this typical tongue is not always so marked as to be 
depended upon for diagnosis in otherwise questionable cases. 
Like all other features of the disease, this one is subject to all 
sorts of vagaries, but when present it is, as before stated, 
"pathognomonic." 

The vomiting or empty retching is of little or no significance 
when occurring as an initial symptom. It occurs perhaps in 
three-fourths of all the cases, irrespective of gravity, and means 
nothing more than a sympathetic irritability of stomach, show- 
ing a derangement of the nerve centers of the sympathetic sys- 
tem. If this vomiting is persistent, however, or recurs after 



292 THE DISEASES OF CHILDREN. 

the eruption has manifested itself, it is a matter of the gravest 
import. 

It is by no means rare for convulsions to occur, as among 
the first symptoms of scarlet fever, especially with infants and 
young children of nervous temperament. Convulsions, like 
vomiting, occurring early in the disease, and preceding or ac- 
companying the eruption, are of no special significance. They 
do not indicate malignancy, nor do they point to any special 
complication in the absence of other symptoms, referable to 
special organs. When convulsions either begin after the 
rash has made its appearance or having begun earlier, persist 
after this period, they are of grave import and indicate a serious 
poisoning of the nerve centers. The brain is not apt to be 
seriously involved in simple scarlatina. 

Among the initial symptoms, it is common to find dilated 
pupils, and an excited state of the cerebral functions. The 
mind is excited and in a state of exhilaration, in spite of pro- 
found bodily exhaustion. 

General physical weakness is the rule even in mild cases, but 
the mental condition varies greatly according to temperament 
and previous state of health. 

A m.ild delirium is frequently noticed during sleep, which is 
quite peculiar to the disease and which, when present, may help 
to differentiate the diagnosis. This delirium is most noticeable 
during the first night or two, and seldom lasts more than three 
nights. It strongly resembles the '* night terrors " of childhood, 
and is of only momentary duration. The child, for example, 
wakes out of a quiet sleep, and for a few moments, talks inco- 
herently, fails to recognize its mother or other attendant, cries 
and calls for some person or thing already within its reach. It 
does not seem to know where it is; wants to be taken home or 
go somewhere. In another moment the mind clears up and 
after a drink of water or a sup of nourishment, quiet sleep is 
renewed, to be interrupted again after an interval of twenty or 
thirty minutes, by a similar repetition of phenomena. This de- 
lirium is quite characteristic of scarlet fever, and is due to an 
excited or exalted state of the cerebrum, quite different from 
that produced from other forms of fever. The writer remem- 
bers distinctly the dreams and visions which accompanied his 
attack of this malady when a lad of twelve or thirteen years 
of age. 

In the simple as well as in the severer forms of scarlet fever, 
there is always more or less sore throat. The angina may be 
slight, in the mildest cases, but it is present in all. Without 
sore throat there is no scarlet fever. There may be but a 
moderate exanthem and a severe angina, and the exanthem 



SCARLATINA; SCARLET FEVER. 293 

may be intense, and even confluent, with but a moderate amount 
of angina ; but whichever predominates, there cannot be one 
with an entire absence of the other. The two are absolutely 
necessary to constitute the simple or regular form of the disease. 
When the throat affection is mild in the beginning, it usually 
intensifies as the disease progresses, and reaches its maxi- 
mum along with the eruption, subsiding as the latter subsides. 
The temperature is subject to remissions and exacerbations. 
In the beginning of the disease it is not uncommon for the 
temperature to suddenly rise to 102° or even to 105° Fahr., 
and to maintain this intensity during the period of eruption. 
Sometimes this elevation of temperature is reached at a 
bound ; in other cases it is a gradual rise, while in either 
case it is apt to diminish gradually with the subsidence of the 
rash. 

Some observers have noticed a peculiarly sweet odor to the 
breath in cases of scarlet fever, where the throat affection has 
been slight, but this is probably imaginary ; it certainly is not 
marked enough to attract the attention of many authorities, 
and is surely not as pronounced as the peculiar bodily odor, 
which is common enough in measles to attract general notice, 
especially when many cases are aggregated. 

The pulse is generally high from the beginning to the end of 
the disease. It is not unusual for it to range as high as 140 or 
160, even in mild cases, and this rate per minute is frequently 
maintained throughout the eruptive stage. 

The urine is high colored from the first, and is usually scanty, 
even when the kidneys are not perceptibly affected. It is nec- 
essary, however, to keep close watch over the urine, for even in 
the first few days, there may be detected evidences of renal 
catarrh, which, if neglected, may eventuate in serious nephritis. 
These evidences are seen in mucus casts, ephthelia, debris and 
blood corpuscles, and traces of albumin. 

By the second or third day the eruption begins to fade and 
disappear in the order in which it came. 

The flush of the face, which is usually well marked in the first 
few hours of the fever, is first to disappear. It is not always 
present even in otherwise well-marked cases. The legs and 
feet are the last to part with the evidences of its presence. 
Desquamation, or peeling of the cuticle, next follows ; but this 
is as erratic and uncertain as are all the other phases of the dis- 
ease. Sometimes desquamation begins as early as the third or 
fourth day of the eruption, but more often it is not perceptible 
until the rash has entirely disappeared from the surface. It 
then shows itself in furfuraceous scales about the neck and hands 
and feet. On the palmar and plantar surfaces, where the cuticle 



294 THE DISEASES OF CHILDREN. 

is thicker, it loses its furfuraceous character, and is peeled off 
in patches or strips. The extent of the exfoliations is, in 
general, comparative to the intensity of the exanthem. When 
the latter is mild, and the skin soft and delicate, the scaling is 
branny and slight; when severe, it is lamellar and abundant. A 
repetition of the desquamative process has been noticed, in 
vi'hich case the skin remains in a sensitive condition for a long 
period. In any event, and without regard to the extent of 
desquamation, the skin is left by the eruption in an extremely 
sensitive state, and this sensitiveness is shared also by the kid- 
neys ; so that a slight cold or exposure is apt to be disastrous. 
This is equally true of mild as of severe cases ; indeed, it is a 
matter of general observation that cases which have been mild 
and apparently devoid of danger in their early stages, are the 
very ones most likely to go wrong in the sequelae. An explan- 
ation of this fact might be sought in the mild character of the 
disease, and the consequent lack of care which severer cases 
would naturally receive. But this will not explain the clinical 
fact that mild cases — even the mildest — are so often the sub- 
jects of complications and sequelae, and this in spite of every 
precautionary effort. This is more apparent in some epidemics 
than in others. As has already been stated, in some years all 
cases are so mild, so regular and so uncomplicated as to mislead 
the inexperienced and the unwary into thinking that scarlatina 
is a disease of but trifling character — that its dangers have been 
overestimated, or that new methods of treatment have robbed 
it of all virulence. 

The fact, which has been often exemplified, that serious mis- 
chief may be developed speedily and without warning even in 
the mildest cases, and whether the disease is sporadic or epi- 
demic, should be a warning to the young physician, and should 
make him particularly watchful and careful until perfect health 
has been fully established. 



IRREGULAR FORM. 

The usual sequence of symptoms, in the regular or typical 
form of scarlatina, as already described, is subject to many 
variations, both as to intensity and duration, without transcend- 
ing the limits of this classification ; but peculiarities of consti- 
tution, pre-existing disease, local surroundings, epidemic influ- 
ences, errors in management, or other perturbating causes may 
so disturb the natural or normal course of the disease as to 
sometimes render the diagnosis difficult, or modify the prog- 
nosis in a given case. The febrile phenomena may be greatly 



SCAT? LA TINA ; S CA RL E T FE VER. 295 

intensified ; the exanthem may be either partial or nearly absent ; 
the angina may be accompanied by ulceration of, or exudation 
on the tonsils ; nephritis may develop early, and be the most 
prominent feature of the disease throughout its entire course ; 
the fever, while moderate in its intensity, may persist, without 
any apparent cause, beyond the usual limit and be character- 
ized by inexplicable remissions and exacerbations. When the 
nervous system is greatly disturbed in the course of scarlatina, 
it maybe considered an irregularity, for in its simple form there 
is no such manifestation. The same may be said of affections 
of the ear and the brain. Otitis is not by any means a common 
or necessary accompaniment of the disease in its regular form. 
In the irregular variety, however, an inflammation may be 
excited in some portion of the auditory apparatus, and the me- 
ninges of the brain may also be involved. The lymphatic and 
glandular structures are very prone to become implicated, and 
when this is the case the inflammatory process may progress to 
the formation of abscesses. When scarlatina occurs in a child 
already affected with entero-colitis, the eruption is apt to be 
delayed or may be suppressed altogether. When entero-colitis 
occurs in the course of scarlatina, it is very sure to modify its 
symptoms in one way or another. If occurring early in the 
disease, the eruption quickly recedes, and may not again mani- 
fest itself. Whenever the eruption is either delayed or sup- 
pressed, or disappears prematurely, and this state of affairs is 
accompanied with an aggravation of the fever, it constitutes a 
very grave condition. 

At any stage of the disease the regular may be suddenly 
transformed into the irregular form, and this, without any cause 
with which science is familiar. A case which may have been 
going on in the most straightforward manner, with a typical 
temperature and every symptom indicative of a favorable out- 
come, may thus take on irregularities of one kind or another, 
and in a few hours assume features of the gravest import. This 
may occur independently of any perceptible local affection, and 
so far as we are able to judge may be independent of any con- 
stitutional dyscrasia. 

With our present knowledge, it is difficult to understand 
these clinical experiences, and we can only say that it seems to 
be due to the perverse and erratic nature of the disease, irreg- 
ularity and pathological surprises constituting one of its chief 
characteristics. It is absolutely impossible to indicate all of 
the deviations and incidental derangements which may accom- 
pany an attack of scarlatina. The physician should under- 
stand this, and be prepared for such emergencies, however 
suddenly they may arise. 



296 THE DISEASES OF CHILDREN. 

MALIGNANT FORM. 

Fortunately this form of scarlatina is not nearly so common 
as those which have previously been described. Some epi- 
demics are peculiarly free from malignancy, all of the cases 
being comparatively benign and uncomplicated. In most epi- 
demics, however, there will occur occasionally one or more 
cases of such severity and quick fatality, that the term *' malig- 
nant '* is the only appropriate designation. In such cases the 
nervous phenomena are intense ; the initial symptoms may be 
attended by convulsions, which rapidly result in coma and 
death. The fever is high from the commencement, with head- 
ache and delirium. The temperature may rise to 105° or even 
107° Fahr. at a bound, and continue at this height for one, two 
or more days, when death usually takes place. Sometimes in 
these malignant cases, the eruption never finds outward expres- 
sion. The disease comes on like an explosion. Its dangerous, 
if not fatal character is apparent from the onset. Some of these 
malignant cases are markedly adynamic in character, great 
exhaustion of the vital forces being an early and conspicuous 
feature. In others the symptoms are most violent and appall- 
ing. In the latter, the delirium very soon drifts into a fatal 
coma. In some instances the stupor or coma is interrupted by 
spasms of longer or shorter duration. When cases, which show 
this malignant character at the beginning, do not reach a fatal 
termination in the first twenty-four or forty-eight hours, there 
is apt to be a lull in the symptoms and a return of conscious- 
ness, with an abatement of fever and a diminution in the rapid- 
ity of the pulse. Sometimes this remission is of permanent 
character, the disease takes on a milder form and health ulti- 
mately results. But more often, when the initial symptoms 
have been thus violent, the apparent improvement is illusory 
and temporary. The system is broken by the virulence and 
malignancy of the attack and the recuperative powers are inade- 
quate to withstand the shock. In some cases, after the subsi- 
dence of the violent symptoms, which marked the onset of the 
malady, and just as the improved condition has stimulated 
hope, new phenomena present themselves, which show how 
deeply as well as suddenly the scarlatina poison has permeated 
the system. These phenomena are manifested in severe inflam- 
mations of the fauces, membranous deposits on tonsils, or 
inflammation and induration of the lymphatic glands and cel- 
lular tissues about the neck All of these manifestations are 
more serious than if occurring idiopathically, for they are not 
mere surface indications — not trivial congestions of unimport- 
ant organs, but indicate a poisoned state of nerve centers and 



SCARLATINA; SCARLET FEVER. 207 

a consequent derangement of cell structure. There is a fateful 
undermining of the very center of Hfe, as if a poisonous flood 
had swept over the organism. 

When life in these cases is not instantly imperiled or when 
there is an effort at reaction from the nervous shock, suffi- 
ciently strong to give opportunity, this flood of poisonous 
material is prone to show itself in a purulent and abundant 
coryza or in a catarrhal angina, and also in a destructive 
otorrhea. 

In grave or malignant cases of scarlatina, all of the essential 
symptoms which constitute the disease are liable to be intensi- 
fied, or appear out of their usual order or sequence. In one 
case the nervous phenomena may be paramount ; in another the 
throat symptoms may overshadow all others, constituting the 
anginose variety of scarlatina of some authors. In still others, 
the eruption may be so extensive and confluent as to quash 
the exhalant function of the skin, and thus produce the sam.e 
effect as would result from a burn of equal extent. Uremia to 
the extent of intoxication is another of the accidents or effects 
which is liable to occur in these cases of malignant disease, 
when the kidneys, instead of the skin, are principally affected. 
It occasionally happens that a malignant case of scarlet fever 
does not show its malignancy at the outset, but starts off in an 
apparently benign, but somewhat irregular way, and only takes 
on a severe character after several days have elapsed after the 
initial symptoms have exhibited themselves. 

In these cases, however, there are eccentricities manifested 
that should excite apprehension. There is not a full and gen- 
eral diffusion of the eruption. It appears in patches, and is 
bluish rather than scarlet. 

There is good ground for the popular domestic idea that 
there is safety in having the '' rash well out." If the disease 
does not find full expression on the external surface, it is quite 
sure to find it elsewhere, on the mucous surface, or oftener 
still, in the excretory glandular system. 

COMPLICATIONS AND SEQUELAE. 

The dangers incidental to scarlatina are not confined to the 
initial lesions, nor are they apparent to the closest scrutiny 
during the early stages of the disease. The erratic nature of 
the malady, and the variableness of the symptoms excited in its 
subjects, are not alone responsible for the terror with which the 
laity looks upon an invasion of scarlatina into its midst. When 
the disease runs a mild course in an otherwise healthy child, it 
means merely a week's illness and a week or so of comfortable 



298 THE DISEASES OF CHILDREN. 

convalesence. Multitudes of cases occur so benign in character, 
and so devoid of all signs of danger, that one might, like 
Sydenham, think it scarcely worthy of consideration. But any- 
thing like an extensive experience with its peculiarities will 
divest one of all feelings of security, and confirm the general 
feeling of dread and apprehension with which it is everywhere 
encountered. Severe cases are always dangerous. Mild cases, 
as already pointed out, are liable to take on serious aspects at 
unexpected moments. But probably not one-half of the mor- 
tality in scarlatina results from the direct effects of the disease. 
The other half of the mortality can be attributed to the effect 
which the disease produces on latent tendencies, constitutional 
defects, or remoter results of the scarlatinous poison on essen- 
tial organs, which were not recognizable during the legitimate 
course of the disease. 

Symptoms. — It has heretofore been stated that inflammation 
of the faucial surface is a general, if not necessary accompani- 
ment of scarlet fever. It is possible that, as some authorities 
state, cases do occur without any evidence of throat affection 
whatever ; but to the mind of the writer such cases are very 
questionable, and cannot properly be regarded as scarlatinal 
unless indubitable evidence is present of exposure to the con- 
tagium and other evidences are found of distinctive character, 
on which to found a diagnosis. As a rule, to which there are 
few if any exceptions, there is more or less angina. It usually 
precedes the efflorescence on the skin, and may sometimes be 
detected some hours in advance of the latter. 

In the anginose variety of scarlet fever the throat symptoms 
are severe. There is pain on swallowing ; the whole faucial 
surface is inflamed and infiltrated ; the tonsils are swollen 
and painful — usually more so on one side than the other, but 
occasionally on both ; the secretions are more abundant than 
normal and are foul in character. When the sore throat, how- 
ever mild or intense, appears in the beginning or early stages 
of the affection; it is to be regarded as a natural accompaniment 
of the disease ; but when, as sometimes happens, a true diph- 
theria is developed, with its characteristic, deeply imbedded 
exudate and other well-marked features, it is not a natural part 
of the malady, but is a complication and one that is greatly to be 
dreaded. So also if the inflammation, swelling and induration 
of the lymphatic glands and cellular tissues about the neck, 
which are among the common accompaniments of severe cases, 
extend to the throat so as to embarrass respiration and threaten 
edema of the glottis, such a condition would be a complica- 
tion. In scrofulous subjects the disease is apt to be compli- 
cated by abscesses and by involvement of the mesenteric glands. 



SCARLATINA; SCARLET FEVER. 299 

Purulent catarrh of the posterior nares, otorrhea, otitis, syn- 
ovitis, and endocarditis are occasional complications. Pleuritis 
is more common than bronchitis or pneumonia. 

Among the sequele of scarlatina, dropsy is by far the most 
common, as a result of acute nephritis. It may affect the serous 
cavities and the internal organs and cause edema of the lungs, 
ascites, hydrothorax, hydropericardium, or hydrocephalus ; but 
it is much more apt to attack the sub-cutaneous tissues, when 
it is known as anasarca. 

It is stated by most authorities that anasarca is present in 
about one-fifth or one-sixth of all cases, but in the experience 
of the writer this is gross exaggeration. We have notes of fifty- 
three cases in our case books, in which dropsy in any form is 
mentioned as complicating the disease in only three instances. 
Anasarca usually occurs in the course of the second or third 
week of the disease. It rarely shows itself before desquam- 
ation has begun, and more often toward the end of this process. 
It follows mild or moderate more often than severe cases, 
and is commonly attributed to the influence of cold; but this is 
probably an erroneous opinion, for it happens quite as often as 
otherwise, in cases where every precautionary measure has been 
taken. It is doubtless due to changes in the kidneys, induced 
by some peculiarity in the scarlet-fever poison. Just how these 
changes are produced and why, are questions hard to answer. 
When the kidneys are examined directly after a dropsy has 
occurred, they are found congested, the uriniferous tubules 
are in a catarrhal condition and an epithelial desquamation more 
or less extensive is in progress. 

Occasionally a croupous inflammation of the tubules is no- 
ticed. The morbid processes commence at the malphigian 
bodies, and extend to the uriniferous tubules. Cloudy swell- 
ing of the epithelial cells characterizes the anatomical changes 
during the first week. Infiltration soon takes place around the 
tubules, which become stufTed with these clouded and enlarged 
epithelial cells, or with granular matter, resulting from their 
disintegration. Sometimes abscesses form in the substance of 
the kidney (kippox). The first noticeable indication of nephri- 
tis is a pufifiness of the eyelids; and soon after the face takes 
on a puffed and bloated look. From the face it extends over 
the body, and if the anasarca becomes general, it is apt to be 
attended by more or less ascites. 

Previous to the appearance of dropsical symptoms, there is 
usually an exacerbation of the fever. There is anorexia, rest- 
lessness, and perhaps nausea and vomiting. The urine becomes 
high-colored and scanty, and if critically examined, will be 
found to contain albumen and exudative casts. It should be 



300 THE DISEASES OF CHILDREN. 

remembered that the great danger from scarlatinous nephritis 
lies mainly in the failure to discover its presence, until grave 
symptoms appear. The urine of a child sick with scarlatina 
should, if practicable, be examined daily as to its quantity, spe- 
cific gravity, and a frequent test for albumin should be made. 
Diminution in the quantity of urine generally precedes both 
the albuminuria and the dropsy, although both are apt to 
follow quickly thereafter. 

If the early symptoms of a renal catarrh be overlooked or 
neglected, it may speedily become a serious complication, while 
if recognized in its incipiency, it is usually very amenable to 
treatment. 

In some cases the urinary secretion is totally suppressed, 
and then the dropsy makes rapid progress ; there is morejor 
less headache, sudden and marked elevation of temperature, 
vomiting more or less persistent, and finally convulsions, coma, 
and in all probability, death. The convulsions may be clonic 
or tonic, partial or general. 

In mild cases, where the urinary secretion is only partially 
suppressed, and prompt measures are employed to relieve the 
local congestion, the anasarca begins to decline after two or 
three days, the untoward symptoms disappear, and the urine 
becomes normal. 

Diagnosis. — In the majority of cases, the diagnosis of scarlet 
fever is not attended with difficulty. It is only in exceptional 
cases, occurring in the absence or incipiency of an epidemic, 
and where the initiatory symptoms are ill-defined, that a mistake 
is likely to occur. A sudden attack of fever, especially if 
occurring in the morning, with more or less angina, is always 
to be looked upon with suspicion. If the disease is prevalent 
in the neighborhood, or if there is any history to be had of 
exposure in a susceptible subject, there need be little ground 
for doubt. This is especially true of the mild or regular form of 
the disease. 

In the irregular form, especially when the exanthem is scanty, 
the angina will surely be present, and so also, the vomiting and 
the fever. 

The tongue rarely fails to show its characteristic coating 
which when present, is pathognomonic. 

Doubtful cases occasionally occur, in which cervical lymphad- 
enitis or a mild nephritis constitutes the entire picture. Ab- 
sence of the prodromal stage ; presence of the strawberry 
tongue; the early appearance of the eruption and its finer 
character, will serve to distinguish scarlatina from measles. 
The coryza and the cough are natural accompaniments of 
measles, but not of scarlatina. In rotheln or German measles, 



5 CA I? LA TINA ; S CA RLE T FE VER. 301 

the eruption is scattered, there is no angina, and the constitu- 
tional symptoms are relatively very mild. Erythema and rose- 
ola sometimes closely resemble scarlatina, but both lack the 
characteristic tongue, the angina and the glandular complica- 
tions. In both the former affections the cxanthem is more local 
and confined to certain portions of the body, while the scarla- 
tinous eruption is more extensive and more equally diffused. 
A few hours will suffice to dissipate all doubt in these simili- 
tudes. 

Scarlatinous dropsy is easily distinguished by its acute 
course, by its beginning about the face and thence extending 
to the serous cavities, and by its occurring in children, during 
or subsequent to an attack of the fever. A previous or accom- 
panying desquamation and associate enlargement of cervical 
glands will still further assist the diagnosis. 

For the differential diagnosis the reader is referred to the 
close of the chapter on Roseola. 

Prognosis. — The prognosis in scarlet fever should always be 
guarded. It is largely influenced by the type of the prevailing 
epidemic, the character of the attack, the vigor and age of the 
patient, and more especially by the presence or absence of serious 
complications. 

The development of scarlatinous nephritis Is not necessarily, 
even in its graver forms, a fatal complication. If recognized 
before renal degeneration has gone beyond restoration, there is 
no reason to abandon hope. Many of these cases recover, even 
after convulsions have occurred. At the same time, clinical 
experience teaches us that all nervous disturbances, and all in- 
flammatory complications increase the danger of the disease. 
The most trivial complication may quickly alter the aspect of 
the case, and change the prognosis from favorable to unfavor- 
able. A temperature rising rapidly to 105° Fahr., or continuing 
for a length of time at or above this figure, especially after the 
beginning of desquamation, is unfavorable. Pyemia and sep- 
ticemia are usually fatal. Abundant hemorrhagic extravasa- 
tions, hematuria, and evidences of the hemorrhagic diathesis, 
are always signs of an unfavorable prognosis. 

Favorable symptoms are : a temperature below 104° Fahr. ; a 
pulse not exceeding one hundred and twenty beats per minute ; 
the absence of serious cerebral and throat symptoms ; a fully 
and regularly developed rash of a bright scarlet color, and a 
copious flow of non-albuminous urine. 

Duration. — In mild and uncomplicated cases the duration of 
the febrile stage of the disease is from five to seven days. In 
very mild cases it may be even less than this. But even in 
such exceedingly mild cases there is no security until after 



302 THE DISEASES OF CHILDREN. 

several weeks have passed, and the patient cannot be consid- 
ered as out of all danger, until some time after all evidences of 
desquamation have vanished. Some years ago the New York 
State Board of Health addressed a circular to the more promi- 
nent physicians of New York City, asking them how long before 
a pupil having had scarlet fever should be permitted to return 
to school. The answers returned varied from six to eight 
weeks. For the shorter period at least, the child recovering 
from scarlatina should be restricted in its intercourse with other 
children, and should be more or less under observation and care. 

Mortality. — Scarlet fever is universally regarded as the most 
fatal of all the exanthematous diseases. Unfortunately for 
statistics, there is no strict law in this country compelling phy- 
sicians to report their non-fatal cases of any of the contagiums. 
In the large cities a faithful record is kept of all fatalities, but 
the relative mortality in a given disease is mere guess-work. 
In the epidemic of scarlet fever which visited Chicago in 
1876-7, there were, during fourteen months, eleven hundred 
and thirty-eight (1138) deaths from this cause. From the 
number of cases of the disease reported to the health ofificer, 
Dr. DeWolff, who was then commissioner of health, estimated 
there must have been within the city limits, during these four- 
teen months, from ten thousand to twelve thousand cases, 
which would give a mortality of about ten per cent. This is 
about the usual estimate in severe epidemics of wide extent. 
Dr. Charles W. Earle, of this city, who studied this epidemic 
very carefully, endeavored to verify or correct these statistics 
by getting the number of cases treated by the leading physi- 
cians. He estimated the number of cases as not less than four- 
teen thousand. If his figures are approximately correct they 
would reduce the mortality to about eight per cent. The mor- 
tality in sporadic or widely scattered cases is always less than 
in epidemics and less in the country than in the city. It is 
always greater in hospitals and asylums than in private practice. 
It varies greatly with seasons and with the circumstances of life. 

In the regular form death is generally due to some compli- 
cation. 

The young physician cannot be too strongly impressed with 
the fact that scarlet fever, pure and simple, is a mild and self- 
limited disease, but at the same time it is the most treacherous, 
the most uncertain, variable and dangerous of all the exanthems. 
Constitutional defects are especially liable to be developed and 
cause trouble in the course and particularly after the disease 
has apparently spent its force, and all symptoms seem to be 
satisfactory. In a word, the sequelae are ever and always to 
be more dreaded than the disease itself — and vet these 



SCARLA TINA ; SCARLE T FE VER. 



303 



sequelae may often be controlled, if not prevented, by early 
recognition and prompt treatment. 

The following table of mortality from scarlet fever, in this 
city, is not without interest. 

Comparative Mortality in the City of Chicago from Scarlet 
Fever (in Children Under 5 Years of Age) by Quar- 
ters, FOR the Eight Years beginning 18S5, with 
Yearly and Quarterly Totals. 



Quarters. 


iSSs. 


1 886. 


1887. 


1S88. 


18S9. 


.890. 


1S91. 


1S92. 


Total 

for 
Quar- 
ters. 


Winter 

Spring 

Summer 

Autumn 


75 
70 

89 


70 
64 
40 
46 


66 
39 


41 
50 
41 

52 


51 
55 
39 
40 


74 
42 

30 

47 


160 

108 

81 

150 


152 
99 
53 

78 


689 

527 
3S6 

530 


Totals by jrs. 


279 


220 


190 


184 


185 


193 


499 


382 


2132 



Prophylaxis. — Every case of scarlatina, however mild, is both 
contagious and infectious, and the attending physician will not 
have discharged his full duty in a given case, until he has taken 
every warrantable precaution against the further spread of the 
disease. During the first few days after the attack, the disease 
is only mildly infectious. By some it is maintained that it is 
only so after desquamation has begun. The safest way is to 
guard against dissemination, as soon as the nature of the mal- 
ady has been clearly recognized. To this end, the patient 
should be rigidly isolated ; and if possible, a light and well- 
ventilated room on the top floor of the house should be selected 
for the temporary hospital, or in case of an apartment, the 
room should be the one most quiet and free from intrusion. 
This room should be stripped of all superfluous furniture. Car- 
pets, rugs and hangings should be removed, leaving only those 
things that are considered absolute necessities. The bedding 
and linen should be chosen with reference to their destruction 
after they cease to be needed. Only such books and play- 
things should be allowed to remain as can be burned ultimately. 
The patient should be anointed daily or oftener with some 
unctuous substance, so as to fix the dusty particles of the exfoli- 
ating epidermis during desquamation and to prevent their being 
widely disseminated. For this purpose, olive oil is as good as 
anything, or mildly carbolized vaseline may be used. A pleas- 
ant preparation is made of cocoa butter, scented with almond 



304 THE DISEASES OF CHILDREN. 

oil. This is prepared by some of our city druggists and dis- 
pensed under the name of " Unguentum Grecorum." 

The attending physician should have a linen duster in an 
adjoining apartment that he can slip on before entering t4ie 
sick room and discard after leaving it. The nurses or attend- 
ants should not mingle with the well members of the family, 
until desquamation is completed. When this process is over, 
and as soon as the attending physician deems it prudent, the 
patient should be given a bath of warm water and soap, followed 
by a brisk rubbing with dilute alcohol. For some time subse- 
quently, great care should be exercised to avoid exposure, for 
a scarlet-fever convalescent is wonderfully susceptible to cold. 

As soon as vacated, the sick room should be thoroughly dis- 
infected by the burning of sulphur, after which it should be well 
aired, the walls newly calcimined or freshly papered, and the 
woodwork and floors scrubbed with carbolized water and soap- 
suds. The mattress and bed linen, as well as the body clothing 
which has been used in the sick room, should be disinfected or 
destroyed by burning. The use of disinfectants about the 
room during the illness is of questionable utility. 

A well-moistened sheet hung in the doorway is useful in 
preventing the poisonous emanations from infecting other 
portions of the house. Carbolic acid or other offensive dis- 
infectants should never be used. Such inodorous prepara- 
tions as Piatt's chlorides or permanganate of potash are far 
preferable. 

As to the value of belladonna internally administered as a 
prophylactic in this disease, there is some divergence of opinion. 
The great weight of evidence, however, is in its favor. It is 
neither a specific in all forms of the disease as a curative rem- 
edy, nor can it always be depended upon as a reliable preven- 
tive ; but there is unquestionable and ample evidence to show 
that when it does not prevent an attack it modifies and controls 
its severity. The writer always administers it to the well 
members of the family, who are not already protected by a 
previous attack of the disease, and he has never yet seen a 
severe case of scarlet fever that had previously taken the 
remedy. As a prophylactic, belladonna should not be given 
lower than the sixth decimal dilution, probably the twelfth 
would be equally efficacious. But belladonna is not the only 
remedy which has been used and highly esteemed by many for 
its prophylactic powers. Dr. Samuel Lilienthal says in the 
''Transactions of the American Institute of Homeopathy " (vol. 
1880): *' What is malignant scarlet fever? It may be answered 
in two words, albuminuria and uremia; that peculiar kind 
of blood poisoning resulting from the change of urea into the 



5 CA RLA TINA ; S CA RLE T FE VER. 305 

carbonate of ammonia ; and carbonate of ammonia, or rather 
the sesquicarbonate of ammonia, has been for ages a favorite pre- 
scription in zymotic diseases, with physicians of the old school. 

" My friend, Dr. John C. Morgan, of Philadelphia, acknowl- 
edged with great satisfaction, that his success in the treatment 
of this, fearful disease arises from the early and steady employ- 
ment of this salt, a drug perfectly homeopathic to the disease, 
and thus he prevents that very decomposition of the blood 
w^hich is the cause of the ammoniemia. Look at the symp- 
toms of the drug, and I doubt whether in our whole materia 
vicdica there is a drug whose every symptom is so characteris- 
tic of this disease. Strong febrile irritation, red diffused spots, 
with sensation of heat and subsequent desquamation, espe- 
cially of the trunk, arms, and thighs ; inflammatory swelling of 
tonsils, and of the sub-maxillary glands ; angina, with viscid 
phlegm ; putrid sore-throat and gangrene ; feeling of great 
prostration ; catarrhal condition of the kidneys and bladder, 
with scanty and painful discharge ; and the thought must im- 
press itself upon our minds, if generalization could be allowed 
in our school, that the sesquicarbonate of ammonia deserves 
far more to be used as a preventive than the so-much-vaunted 
belladonna." 

Treatmejit, — It cannot be too strongly impressed upon the 
student and the practitioner, that there is no one specific for 
scarlatina. A disease which is so variable in its manifestations ; 
so eccentric in its course ; so full of surprises, even in its mild- 
est form cannot, in the nature of things, be treated successfully 
in a stereotyped way. In fact there is no disease, unless it be 
entero-colitis, in which so great a range of remedies is likely to 
be needed. 

The value of belladonna in the regular form of the disease, 
and especially when the eruption is smooth and the angina of 
mild type, is very great, and if the cerebral symptoms are in 
correspondence with the drug, its effect is marvelous. But in 
the irregular and malignant forms of the disease, there are 
other remedies of far greater merit. Apis, ailanthus, arseni- 
cum, gelsemium, mercurius and terebinthina, are drugs that 
will frequently be called for, and will greatly excel belladonna, 
in their curative effects. In the first onset of an attack, and in 
the absence of symptoms calling for some other drug, aconite 
and belladonna will be most commonly indicated. In severe 
cases, especially when attended with great prostration and 
typhoid tendencies, rhus tox., arsenicum, veratrum viride, 
ammonia sesquiox., or %olanum, may be required. In cases 
which show great malignancy, arsenicum, lachesis, ailanthus, 
and camphor are to be remembered. 
D.C.— 20 



306 THE DISEASES OF CHILDREN. 

Where there is great restlessness, gelsemium will be found 
of value ; for the nocturnal delirium, hyoscyamus or passiflora. 
On the first indications of dropsy, apis or arsenicum will be 
needed. The choice between the two remedies will depend on 
the rapid swelling of the throat, and sharp stinging pains in the 
fauces ; when the rash is interspersed with a miliary eruption, 
and when with suppression of eruption there is also suppression 
of urine, all of which symptoms indicate apis. Arsenicum is 
indicated in malignant cases, when there is great prostration of 
the vital powers ; when there is great thirst, and when there is 
a fetid discharge from the nostrils (ailanthus).^ 

For anasarca and threatened hydrocephalus, helleborus nig. 
is the chief remedy. 

But the reader is referred to the following list of remedies 
and their chief indications, a careful study of which will be 
sufficient to differentiate. 

Aconite. — Intense restlessness; very irritable; skin very hot, 
dry and congested ; face expresses fright and anguish ; head- 
aches ; intense burning thirst ; in stomach in later periods, sud- 
den violent, burning, shooting pains ; sweat on whichever side 
patient lies ; severe retching with vomiting of green mucus, 
mixed with bile or blood. 

Ailanthus. — Face flushed and burning; restless, yet at the 
same time very drowsy, which increases to insensibility, with 
low, muttering delirium ; severe headache with photophobia ; 
eruption of a miliary rash, of a livid color, the intervening 
spaces being of a dull opaque appearance, in patches, mostly on 
face and neck ; excessive vomiting ; tongue dry and cracked ; 
throat dark colored, and in some cases glands are greatly swol- 
len and ulcerated ; skin cold and dry ; the livid color returns 
very slowly when pressed out by the finger. 

Ammonium Carb. — In malignant cases with lethargic condi- 
tions, threatened gangrene ; eruption developed but slightly, 
with stupor, sleepiness, burning pain and dryness of mouth ; 
burnmg pam in throat, which is sore and exhales a foul odor ; 
parotids and lymphatics of neck, especially of right side, hard 
and swollen ; tonsils enlarged and of a livid color and covered 
with a foul smelling mucus which rapidly degenerates ; exces- 
sive vomiting, accompanying threatened paralysis of the brain ; 
head heavy ; breathing stertorous ; stools passed involuntarily. 

Apis. — Unconsciousness, delirium, convulsions, sopor with 
piercing shrieks, cerebral irritation, gnashes the teeth, shrieks, 
rolls the head ; accelerated and oppressed breathing ; pulse slow 
and irregular ; skin changes from hot to cold, or one part hot 

* Bryonia will be found very effective in cases where the exanthem is slpw in appearing 
or appearing irregularly. 



5 CA RL A TINA ; 5" CA RLET FEVER. 307 

and another cold ; discharge of thick, white, bloody, fetid mucus 
from the nose ; great trembling of the limbs; gradual and con- 
stant increase of fever, with frequent changes in character of 
pulse ; swallowing difficult from swollen tonsils ; urine scanty 
and high colored, passed frequently and with stinging pains; 
entire abdomen sensitive to touch ; slimy and bloody diarrhea; 
during desquamation symptoms of dropsy. According to Wolf, 
where the virus thoroughly poisons the blood, the whole ner- 
vous system is under its paralyzing influence ; the fever becomes 
typhoid in character, the tongue deep red and covered with 
blisters, which become converted into stinging sores and ulcers. 

" Never useful in coryza form, only with dryness of nose and 
throat and symptoms of hydrocephalus." — Hcring. 

According to O. P. Baer, the indications for apis are, " skin 
unevenly scarlet and rough, by being covered with hard, sharp, 
pointed rash." In this form of the disease, he says it is as com- 
pletely curative as is belladonna where the skin is evenly scarlet 
all over, smooth and shining. 

Apocynum Cannabinum. — Mind bewildered ; great thirst, but 
water rejected soon as taken ; abdomen distended and painful ; 
scanty urine with no uneasiness in consequence ; profuse light- 
colored urine with no sediment ; general restlessness with debil- 
ity ; excretions generally diminished, especially urine and 
sweat. 

Arnica. — In typhoid conditions, with nose-bleed and bloody 
expectoration aggravated by coughing ; ecchymoses on various 
portions of the body, or even small boils. 

Argentum Nit. — Eruption dark, bluish, or even black, accom- 
panied by convulsions ; convulsions preceded by extreme rest- 
lessness and tossing about ; passage of quantities of greenish 
mucus, with copious emission of foul-smelling flatus. 

Arsenicum.— \n malignant cases, eruption delayed, or sud- 
denly turns pale or livid, surrounded by petechie ; drinks fre- 
quently, but little at a time ; extremely restless and anxious ; 
prostration, mild delirium ; spasmodic action of tendons, 
with violent vomiting; eating or drinking brings on violent 
diarrhea ; lips dark or black, cracked and often bleeding ; 
grinds teeth during sleep ; eating leaves a bitter taste in mouth ; 
great desire for acids and cold drinks ; vomiting of blood and 
mucus ; hematuria ; urine scalding, nd voided with difficulty ; 
edema of eyelids ; cold perspiration and extremities ; tendency 
to dropsy ; must constantly move and change position on ac- 
count of oppression of breath ; great emaciation ; albuminuria. 

Arum TripJi. — Upper lip and nostrils excoriated by sanious 
discharge from nose; mouth, fauces, and posterior nares 
sore ; nose and lips bleed from constant picking ; ulcerous sore 



,^08 THE DISEASES OF CHILDREN. 

throat ; feeling of burning in larynx and fauces, with moist 
cough during day, but at night is compelled to sit up from 
spasmodic cough ; nose obstructed, with or without a thick, 
yellow discharge which fills the throat and nasal cavity ; ulcers 
in mouth, with burning pain and soreness ; tongue raw, sore 
and papille elevated; saliva hot and burning; swelling of left 
submaxilliary glands ; neck becomes stiff ; itching of eruption 
which is spread over the whole body ; urine copious and high- 
colored ; high fever. 

Asclepias Syr. — For dropsy of post-scarlatinal nephritis. 

Aurum Met. — Nose when touched feels sore; discharge of 
offensive mucus from nose ; extremely fetid otorrhea ; caries, 
with passage of small fragments of bone from the ear ; condi- 
tions analogous to mercurial or scrofulous disease, with ten- 
dency to destruction of tissue in the parts affected ; bone affec- 
tions ; painful swelling of submaxillary glands ; mind peevish 
and irritable ; least thing excites anger. 

Baptisia. — Mind wanders, and feels as if portions of body 
were here and there ; face hot and dark-red ; tongue at first 
dry and sore, with a white coating, and red, elevated papille, 
which later changes to a yellowish-brown in center, and dry, 
shining dark-red on edges ; diphtheritic ulcers in throat ; tonsils 
inflamed and swollen ; foul-smelling breath ; great dyspnea ; 
urine scanty, dark-colored and burning ; bloody stools with 
tenesmus ; typhoid conditions ; fever continues, accompanied 
by great weakness and loss of strength. 

Baryta Carb. — During and after desquamation. — Raiie. Sub- 
maxillary glands, tonsils and parotids swollen and painful; 
much saliva in mouth or is very dry ; violent pains and spas- 
modic contractions in tonsils and fauces on swallowing. 

Bellado7ina. — Delirium, accompanying congestion of brain ; 
when asleep, starts up suddenly, dreams, is anxious, or tries to 
get up and walk; feels sleepy, but cannot sleep; on closing 
eyes, sees frightful objects; carotids throb violently ; head hot- 
ter than body ; head bent backwards ; moves hand to head 
involuntarily ; swallowing painful and difftcult, especially fluids, 
which sometimes return through the nose ; nausea and vomit- 
ing; often dreads water, but has violent thirst; glands of neck 
swollen; injection of the eyes; fiery red face, or sunken, or is 
pale and puffed ; tongue coated white and edges red 

" Belladonna is only indicated in the smooth form of eruption, 
with vascular and nervous excitement ; it does no good in ady- 
namic cases. The miliary form of eruption is much more 
adapted to amm. carb. ; lachesis., or rhus. tox." — Raue, 

Bryonia. — Face red and hot ; lips dry and cracked ; while 
asleep does not completely close eyes ; tongue dry and thickly 



5 CA RLA TINA ; S CA RLE T FE VER. 309 

coated brownish-white; large quantities of alkaline, frothy 
saliva; sudden disappearance or delay of eruption, causing 
dropsy, pleuritis or meningitis; motion aggravates all symp- 
toms, while quiet ameliorates ; obstinate constipation ; slightest 
motion brings on nausea and vomiting; excessive thirst for 
large quantity of water, which is retained, while solids are 
immediately vomited. 

Eruption does not appear after third day; face is pale and 
puffed up ; throat greatly inflamed, aphthous condition of roof 
of mouth and tonsils; breathing anxious and oppressed with 
tendency to paralysis of lungs ; glands of neck become hard 
and swollen ; nose ulcerated and stopped up ; no cough ; breath 
very hot ; "otorrhea a sequela." 

Capsicum. — Throat burning and painful, worse between swal- 
lows ; tongue dry and covered with burning vesicles ; redness 
and burning of face, heat of face greater than body; throat and 
mouth burn and are of a deep-red color; tough, sticky mucus in 
mouth and throat, difficult to remove ; variable humor ; vomit- 
ing of phlegm ; no thirst ; excitability of all the senses. 

Carbolic Acid. — Tongue, which at first is coated white, clears 
up and is glossy and red ; foul odor of breath ; fauces bright- 
red and swollen ; breathing and swallowing are dif^cult from 
throat being swollen both inside and outside ; face a dark-red 
color, while around mouth is a white circle: nose obstructed; 
dryness and chapping of lips; slight tympanites of abdomen; 
urine scanty and very dark ; mucus exudation in patches on 
tonsils and pharynx; body covered with a scurfy eruption; 
frequent diarrheic, foul-smelling discharges. 

Coffea Cruda. — Special senses very acute; intense mental 
and physical excitement causes sleeplessness ; body hot to 
touch, but patient chilly ; palpitation of the heart. 

ColcJiicum. — Exceedingly irritable, with an expression of 
suffering on the face; tongue swollen and thickly coated white; 
mouth inflamed, with profuse saliva; smell of food irritates 
him, brings on vomiting ; stools slimy, foul-smelling and exceed- 
ingly painful ; urine dark, like ink, scanty and passed with dififi- 
culty and very painful, burning sensation ; albuminurea ; dropsy. 

Coniinn Mac. — Delirium ; loss of consciousness ; headache 
worse in morning ; burning, shooting pain in lips ; difficulty of 
speech from paralysis of tongue ; salivary glands swollen and 
hard ; vomiting of dark-colored masses, like coffee grounds, 
very acrid ; frequent urination, with burning during and after ; 
black deposits on lips ; skin very hot. 

Ciipruvi Met. — Delirium with mutterings and fragmentary 
speech ; sopor; constant uneasiness and tossing about ; convul- 
sions from sudden recession of eruption ; contractions of flexor 



310 THE DISEASES OF CHILDREN. 

muscles, and also of facial muscles, causing distortions of face. 
*' Clings tightly to nurse, but is afraid of everybody else ; fears 
of falling, or that fire will destroy the bed-clothes ; wants to 
stay in nurse's lap ; eruption does not appear, which causes 
terribly sore throat." — Gardiner. 

Digitalis. — Especially useful in post-scarlatinal nephritis, 
with the following indications : great anxiety, feels as though 
he were dying ; vertigo ; throbbing pain in forehead ; violent 
thirst, with extreme nausea and vomiting: stools colorless, 
nearly white ; urine scanty, dark-colored, passed frequently, 
with burning and little at a time ; edema of lungs ; extremely 
slow, small, weak pulse. 

Gelsemium. — Apathy, wants to be let alone, no desire to 
play or be amused ; frequent, copious discharge of pale urine, 
which slightly relieves dull, aching pain in head ; tongue coated 
thickly white *, eruption slightly developed ; face dull and heavy- 
looking; thickness of speech; intense nervous excitement or 
drowsiness and languor ; tonsils swollen and injected. '* Hands 
and feet cold ; eyes suffused and heavy-looking ; all the viscera 
are threatened when the eruption recedes ; in all positions the 
whole face is a high crimson ; delirious mutterings while asleep 
or half awake; sensation in throat as if it were filled up ; lan- 
guor and drowsiness with heat." — Morgan. 

Helleborus. — Head feels dull and heavy, with stupor and uncon- 
sciousness; photophobia with dilated pupils ; face colorless and 
edematous ; vomiting of dark greenish masses ; painful mucoid 
stools, like thick albumin ; urine scanty, frequent micturition, 
deposits sediment like coffee grounds ; post-scarlatinal dropsy. 
This drug is very useful when the mental condition, viz., semi- 
consciousness approaching coma, is united with suppression of 
urine more or less marked. 

Hyoscyamus. — Arouses from stupor to answer questions, but 
immediately relapses into former condition ; muscles twitch and 
jerk here and there over the body ; extreme sleeplessness and 
nervous excitability ; illusions crowd upon the mind ; eyes red 
and shining, with staring, stupid look ; inability to swallow, with 
dryness and redness of mouth and throat ; watery, painless 
diarrhea, passed involuntarily in bed ; urine scanty and passed 
with difficulty or involuntarily. 

lodiiun. — Great emaciation ; face pale or with a bluish-green 
cast ; blue haze before the eyes ; glands of neck and throat 
swollen and ulcerated : great appetite, but vomits as soon as he 
eats ; all symptoms aggravated by warmth. 

Ipecacuanha. — Vomiting of greenish mucus and bile ; diar- 
rhea of green mucus mixed with blood ; intense itching 
after suppression of the eruption ; moans and keeps eyes half 



SCARLA TINA ; S CA RLET FE VER. 311 

Open during sleep ; difficult, sighing respiration ; cough and 
vomiting. 

Kali-bicJiroi)iic7U)i. — Violent stitches in left ear extending 
from throat when swallowing ; discharge of blood-streaked, 
tenacious, excoriating mucus from nose ; throat dark, livid and 
covered with diphtheritic exudation ; parotids swollen and pain- 
ful ; tongue ulcerated, smooth and red; ulcers on fauces ; pu- 
rulent infiltration of mucous membrane of nose and throat ; 
furfuraceous eruption. 

Kali carb. — Eyelids swollen, and hang down like sacs; 
mouth dry, covered with burning vesicles, and exhaling an 
odor like old cheese ; parotids swollen and inflamed ; burning, 
dry feeling of skin ; very restless, with high fever. 

Lachesis. — Delirium with constant mutteringsand constantly 
changing moods ; dull, heavy headache, with deep-seated pains 
in brain ; discharge from nose watery, bloody, thick and dark ; 
crusts form in nose ; tongue swollen, and so heavy cannot pro- 
trude it beyond the lower teeth ; difficult speech; tongue cov- 
ered with blisters, black, stiff and cracked ; throat so sensitive 
cannot bear the slightest weight on it, glands swollen and sup- 
purating : cannot swallow fluids, they return through the nose ; 
diphtheritic deposit first on left side, then gradually extends 
over the whole throat ; offensive, sudden, watery stools ; fre- 
quent urgings to pass foaming, dark, copious urine ; eruption 
becomes bluish or black, with great dyspnea ; effusion into 
the pleura and pericardium, also general dropsical condition ; in 
malignant cases, with sloughing ulcers, or which become gan- 
grenous and discharges are foul and acrid ; in typhoid states. 
A marked characteristic indication for lachesis is aggravation of 
all the symptoms after sleep. 

LachnayttJics. — Eyes brilliant and sparkling ; much thirst, with 
burning in head like fire ; redness of face in circumscribed spots ; 
throat sore and dry with sticking pains on swallowing; when 
eruption about to appear, there is a sensation of heat and burn- 
ing on the surface. 

Lycopodhun. — Dull, peevish, fretful ; discharge from ear pu- 
rulent ; hair falls out ; patches on right tonsil extending to left ; 
face, hands and feet swollen and puffy; nose stuffed up, with 
acrid discharge from right nostril ; submaxillary and glands of 
neck swollen, hard, and very sensitive ; urine passed frequently 
in small quantities, and with burning ; urine milky, scanty, de- 
posits sand-like sediment ; constipation and colicky pains dur- 
ing desquamation. 

" Secondary eruption of dark-red blotches on thighs, back, 
and face." — Raue. 

Mercurius. — Ears inflamed, sore and excoriated from dis- 



312 THE DISEASES OF CHILDREN. 

charge which is bloody and offensive ; grayish, dirty yellow- 
coating on tongue ; impression of teeth on edges of tongue ; 
mouth sore and covered with vesicles ; salivation ; glands of 
neck and tonsils swollen and suppurating ; itching all over the 
body aggravated by the warmth of the bed or perspiration ; 
foul-smelling breath ; exceedingly painful swelling of bones of 
nose. 

Mercurius lod. Flav. — Swelling and long-standing indurations 
of glands of neck, tonsils and parotids ; tongue covered with a 
thick, dirty-yellow coating, edges red and clean ; pain in left 
ear which is deep-seated and throbbing, and boring in charac- 
ter; infiltration of throat and neck; discharge of very greenish 
mucus from throat and nares ; after lachesis for hoarseness : 
dark, scanty urine. 

Muriatic Acid. — Mouth and throat very dry, ulcerated and 
foul odor ; entire face red, body very hot and skin purple ; up- 
per lip and nostrils excoriated by acrid discharge from nose ; 
fauces dark red, and covered with aphthae ; coma at beginning 
of attack, with rapidly spreading, intense redness ; rapid, small, 
very weak pulse ; in typhoid conditions, patient sinks away 
down in bed ; eruption is interspersed with petechiae ; patient 
so anxious and restless that he cannot keep the covers on ; very 
deep, groaning, audible respirations. 

Nitric Acid. — Mouth and throat very dry and burning, cov- 
ered with deposits resembling diphtheria ; tongue swollen, dry, 
and cracked, hindering speech and swallowing ; offensive, thin, 
purulent discharge from nose and ears ; skin covered with a 
fine miliary eruption and burning hot ; parotids and submax- 
illary glands swollen, with deafness. "All secretions and excre- 
tions exceedingly fetid smelling ; gums dark red, swollen, and 
easily bleeding, with foul odor from mouth ; no swelling of 
fauces, but are darker in color ; vomiting ; exhausting epistaxis 
of dark-red blood." — Kunkel. 

Opium. — Eyes wide open, stupid, easily frightened, sees 
frightful images ; delirious and unconscious, with slow, ster- 
torous breathing ; paralysis of throat, with dryness and inability 
to swallow ; symptoms of cerebral oppression with heavy 
breathing ; retention of scanty, dark-brown urine ; picks at 
bed-clothes ; cannot stay in bed because it is too hot. 

Phosphorus. — Unconsciousness, with low, muttering delirium ; 
congestion of head ; pupils contracted ; fluent coryza ; falling 
out of the hair ; tongue dry, cracked, swollen, brown coating, 
and immovable ; eyes and lids swollen ; deafness, especially to the 
human voice ; thirst, drinks large quantities of very cold liquids ; 
alarming rattling in throat ; suspicious chest symptoms accom- 
panying disappearance of eruption ; uneasiness and restlessness 



SCAI^LA TINA ; SCARLE T FE VER. 313 

from a sensation of burning; pulse exceedingly rapid, small 
and weak ; urine scant}^ dark-brown and deposits a red sandy 
sediment ; diarrhea ; ecchymoses. 

PJwsphoric Acid. — Pulse irregular, frequent, small, weak, 
sometimes palpitation ; throat, mouth and tongue dry, without 
thirst ; involuntary diarrhea, stools thin, watery, yellowish and 
painless; epistaxis of dark-red blood ; quiet, indifferent, stupid, 
even to imbecility, aversion to speaking, cannot answer cor- 
rectly, uses wrong words ; rumbling and gurgling in, and dis- 
tension of, abdomen ; bed-sores of a bluish-red color ; profuse 
sticky perspiration during night. 

Phytolacca. — Throat and fauces dry, sore and congested ; sen- 
sation of a lump in throat when swallowing, also violent pain 
extending to both ears ; tonsils swollen, and covered with 
patches resembling diphtheria ; pains in arms and legs like 
rheumatism ; very restless and sleepless, while hands and feet 
are so hot, cannot keep them covered ; skin is dry and harsh and 
feels like rough paper; eruption dry and shriveled ; urine sup- 
pressed, with violent pains in head, back, and lower limbs. 

Podophyllum. — *' Distressing nausea ; intense, long lasting 
vomiting of dark-green, watery mucus ; useful to control vomit- 
ing when other remedies fail." — RicJiardsoji. 

Rhus Tox. — Impatient, restless, low delirium, with stupor ; 
putrid sore throat, first on left side, then on right ; parotids and 
submaxillary glands swollen and discharging copiously ichorous 
pus ; excoriating discharge from nose ; nightly epistaxis ; tongue 
dry, cracked, and red on edges ; eruption dark red and livid, 
with intense itching over whole body ; eruption of fine vesicles 
which burn and itch ; mouth and throat very dry, causing 
intense thirst for cold drinks ; penis and scrotum swollen. 

Secale. — Raving delirium, with tendency to bite those near 
him ; fears dying ; deep, sighing respiration ; dry, brown or 
blackish tongue, with constant unquenchable thirst ; rapid loss 
of strength, with trembling of the whole body, and great rest- 
lessness ; nose feels stopped up, yet there is a profuse watery 
discharge ; cannot remain covered or bear the least warmth ; 
involuntaiy, very offensive, slimy stools, with scanty discharges 
of bloody albuminous urine. 

Silicia. — Drawing and stitching pains, with roaring in ears, 
when swallowing ; ears so painful that patient puts her hands 
behind them ; in scrofulous patients, glands swell and suppu- 
rate ; suppuration of parotid, which is very much enlarged ; 
otitis media and caries of mastoid processes ; very sensitive to 
cold, takes cold easily, desires to be warm and well covered up ; 
boils and abscesses come in series. 

Stramoiiium. — Delirium, variable mood ; eyes sore and pain- 



"314 THE DISEASES OF CHILDREN. 

ful, pupils dilated, photophobia so intense, that light causes 
convulsions ; tongue yellowish-brown, swollen, stiff and dry ; 
speech difficult or unintelligible from paralysis of tongue ; 
mouth and throat very dry, with violent thirst, especially for 
acids; nausea and vomiting; restlessness, with violent trem- 
blings over whole body ; urine suppressed, and stools are passed 
involuntarily, and are of decomposing, foul-smelling blood ; skin 
dry and hot, rash very fine, dark red and with intense itching. 

Sulphur. — Nose feels sore, dry, stopped up, with fluent 
excoriating discharge ; face swollen, dark red and burning, with 
distorted appearance of eyes ; tongue coated white, red edges 
and covered with brownish mucus ; eruption turns from a 
bright red to dark purple, followed by diarrhea, worse in the 
early mornings; white circle around mouth; mouth and throat 
very dry, swallowing difficult, great thirst ; during stage of 
desquamation, and in scrofulous children. 

" In cerebral affections that do not yield to bell." — Snelling. 

Terebinthina. — Unconsciousness, with intense cerebral con- 
gestion ; violent headaches, relieved by passing large quantities 
of smoky urine ; tongue smooth, bright red and shiny ; great 
thirst, but drinking brings on nausea and vomiting; vomiting 
and diarrhea of yellow mucus and water ; urine scanty, pro- 
fuse, bloody, albuminous, and intensely hot; eruption appears 
very slowly, with burning and tearing pains in kidneys; pulse 
small, thready, and almost uncountable ; edema of upper por- 
tion of body. 

''Albuminuria and dropsy after scarlet fever; urine greenish 
and loaded with albumin ; much thirst, drinking often, but little 
at a time."— y. B. Bell. 

Veratriim Viride. — Delirium, with mutterings, dilated pupils, 
incessant headache, nausea and vomiting, and sleeplessness; 
urine dark, cloudy and bad odor; tremblings, twitchings and 
contortions of muscles ; great prostration ; red streak through 
the middle of yellow coating on tongue; great arterial excite- 
ment, active congestions and intense fever; eruption preceded 
by convulsions, slow, difficult respirations and small, quick, 
irregular pulse ; rheumatism and edema. 

Zincum. — Respirations short and quick, panting; stupor, 
preceded by convulsions ; tendency to brain paralysis ; back of 
head and neck very hot and covered with perspiration ; twitch- 
ings and jerking of single muscles or even the whole body; 
forehead and face cold, pale, distorted and covered with cold 
perspiration ; child is unconscious, perfectly motionless ; body 
and extremities cold, pulse small, quick and thready, skin pur- 
plish ; stools and urine passed involuntarily ; urine scant, bloody 
and hot ; grates the teeth, and every now and then emits fright- 



5 CA RL A TINA ; SCARLET FE VER. 315 

ful screams ; eruption recedes ; mouth and throat very dry, 
with large quantities of mucus in pharynx. 

For suppression of urine, with or without dropsy, there is a 
new remedy of great value, known as Diuretiji, which has 
within the last two years served us when other and better- 
known drugs had utterly failed. It is obtained in the form of 
a white powder, is practically tasteless and does not affect the 
stomach or bowels, even when given in large doses. It may be 
given dissolved in water, milk or any other desirable medium. 
It should be given to a child of two or three years of age, in 
doses of two to three grains, repeated every three hours, until 
its specific action on the kidneys is secured. 

In some cases, its effect is not perceptible until seventy-five 
or one hundred grains have been taken. In one case of post- 
scarlatinal dropsy, to which we were called in consultation, by 
Dr. S. P. Hedges — the child, who was some five years of age, 
took upwards of two hundred grains in the course of three 
days, before its full action was manifested, after which the kid- 
neys performed their function without further trouble. 

This drug will rarely be needed, if other well-verified reme- 
dies are sufficiently studied to be properly afifiliated. 

HYGIENIC MANAGEMENT. 

Much of what might come under this head, has already been 
said when speaking of prophylaxis. 

The sick room should be a quiet one, and as far as possible 
removed from the ordinary living rooms of the family. This 
is essential, not only to prevent the spread of the contagion, 
but also for the comfort of the patient. It should be an ample 
apartment, well ventilated, and kept at a temperature of from 
65° to 70° Fahr. The strictest cleanliness should be maintained 
throughout the course of the disease. 

All handkerchiefs and discarded linen should be burned or 
disinfected before being used again. 

The evacuations from bowels and bladder should be received 
into vessels charged with inodorous disinfectants, and as soon as 
voided should be immediately disposed of. The diet should be 
mainly liquids, and consist largely of milk, koumiss and animal 
or vegetable broths. Distilled water may be given freely. Ice 
may be held in the mouth until dissolved, and will be very 
grateful in the height of the fever. Where prostration threat- 
ens, it may be combated with dilute whisky or brandy. In 
cases where the stomach is intolerant of food, the strength 
may be supported and time gained by the use of nutritive ene- 
mata. For this purpose we have had great satisfaction in the 



316 THE DISEASES OF CHILDREN. 

use of '' Murdock's Liquid Food," diluted one-half with warm 
water. 

When diphtheria complicates the case, the remedies and 
measures should be employed which are fully described when 
speaking of this disease. 

The use of peroxide of hydrogen is so essential in such cases, 
that we make reiterated mention of it here. In cases where 
the eruption is dilatory in appearing, and the skin dry and hot, 
the wet sheet pack may be resorted to without hesitation. 

In the early part of the disease, when the temperature runs 
up to or exceeds 104° Fahr., the body should be sponged off 
frequently with cool or tepid water. 

During the eruptive stage the itching of the skin is some- 
times very annoying. This can be greatly alleviated by rub- 
bing the surface over frequently with olive oil, or the unguen- 
tum grecorum, previously spoken of. When the kidneys are 
involved, hot poultices of linseed meal should be placed over 
the loins, and changed as often as they get cold. 

In anasarca, the hot wet-sheet pack, by opening the pores 
and producing a derivative action, will be found exceedingly 
serviceable. Several packs may be given in the course of 
twenty-four hours, if necessary, and the patient may remain in 
the pack for one or two hours at a time. 

During convalesence, great care must be taken to avoid ex- 
posure to cold ; the clothing should be warm, and when des- 
quamation is fully over, the patient should be well bathed, 
newly clad, and only allowed to exercise moderately until 
health and strength are fully restored. 



CHAPTER V. 

ROSEOLA. 

Definition. — The term roseola, or rose rash, is used so differ- 
ently by different authors, that it is somewhat puzzling to one 
who seeks for a plain and distinctive definition of the word. It 
is so trifling an affection that some authorities ignore it 
entirely, while others only refer to it when differentiating 
other diseases attended by an efflorescence. It so closely sim- 
ulates certain other eruptive fevers, however, notably scarlatina, 
that it should always be borne in mind when the diagnosis of 
this latter disease is in doubt. It is essentially an erythema of 
reflex origin, and usually is due to some trifling derangement 
of the stomach. 

Some children are very subject to it. It is non-contagious, 
and its duration is seldom longer than twenty-four or forty- 
eight hours. More often it lasts but a few hours. It is espe- 
cially common in spring and autumn, and this partiality to 
certain seasons of the year has given rise to the names, ** roseola 
estiva " and *' roseola autumnalis." One attack does not prevent 
its recurrence ; indeed, a child who has once had it is very liable 
under similar provocation, to have it again. It seems to be more 
prevalent in some families than in others. I have one family on 
my regular list in which there are now six children. Three of these 
children have had one or more attacks of roseola, the first one 
being attended by so much fever and redness of the fauces that 
I was quite sure it would prove to be a case of scarlet fever. I 
gave, however, a qualified diagnosis, and the next day the prepa- 
rations which were begun to isolate and care for scarlatina, were 
abandoned, as my patient was as well as ever. In this case there 
was not only the deep scarlet rash pervading the entire body, 
and a sore throat, but also vomiting and a temperature, at the 
time of my visit, of 104° Fahr. Such a case as this is very con- 
fusing, and emphasizes the fact that in all of these eruptive dis- 
eases the physician should act guardedly and give himself time 
for a correction of his diagnosis, should this be necessary. Rose- 
ola is usually caused by some derangement of the digestive 
apparatus, but it occasionally complicates other diseases. Dr. 
Eustace Smith says that it may come on in the " pre-eruptive 
stage of small-pox, and is apt to occur in vaccinated children, 
and in rheumatic subjects." 

(317) 



318 IHE DISEASES OF CHILDREN. 

Symptoms. — Signs of stomach disturbance, more or less pro- 
nounced, usually precede or accompany roseola. Sometimes 
vomiting or diarrhea is present, but this is not uniformly so. 
It frequently happens that a child in previous good health is 
suddenly attacked with symptoms of indigestion, such as nausea 
or vomiting, anorexia, headache and a furred tongue, and soon 
thereafter a fever of more or less intensity, accompanied 
with an efflorescence on the external surface, makes its appear- 
ance. The eruption is very irregular in its manifestation, some- 
times covering only a meager portion, and again extending 
over the entire body. The eruption is quite similar to erysip- 
elas, but lacks its puffy character. It is without elevation of 
the surface, and is evenly diffused over the affected part. 

In these respects it strongly resembles scarlet fever. If a cold 
is at the foundation of the gastric disturbance, a sore throat 
may complicate the symptoms and make the differential diag- 
nosis between roseola and scarlet fever, a problem of extreme 
delicacy. Som.e years ago I was called in counsel by my asso- 
ciate. Dr. Schneider, to see a case which well illustrates the dif- 
ficulties which sometimes present themselves in such cases. 
Mrs. F. had issued cards for a garden party, to which a large 
number of children were included; Two days before the fete, 
her youngest child — a little girl four years old — was taken ill 
with high fever, sore throat and a generally diffused scarlet 
efflorescence. The child had vomited twice before my arrival, 
at ten o'clock P. M. The question of diagnosis was a vital one. 
If it was scarlet fever, the invitations to the garden party must 
be recalled in the morning; but if it was only a transient illness, 
without danger of contagion, there was no necessity therefor. 
I gave the case a very thorough examination. The tempera- 
ture was 104° Fahr.; there was a distinct angina, with a slight, 
but perceptible exudation on the right tonsil ; the body was 
fairly ablaze with a scarlatinous or erysipelatous blush. I was 
on the point of pronouncing the case clearly an attack of scar- 
latina, when the mother said, " I am sure this is only an indi- 
gestion, for she has had two attacks just like this before and 
was as well as ever the next day." 

In view of this statement, which was confirmed by Dr. 
Schneider, I advised waiting until morning, before deciding on 
the diagnosis and recalling the invitations. To my surprise, 
and greatly to the gratification of all concerned, I found, on 
my visit next morning, a complete change in the whole picture. 
The temperature was normal, the throat symptoms were nearly 
gone ; the rash had almost disappeared, and the child was 
pleading to be dressed and to go out to play. 

Better counsel, however, prevailed ; the child was confined to 



ROSEOLA. 319 

bed that day, the diet was restricted and the party was allowed 
to proceed without any bad results following. 

My friend, Dr. W. A. Edmonds, in his work on " Diseases of 
Children," takes a very different view of this disease and insists 
on its possessing a decidedly contagious character. He says: 
" My clinical experience has decidedly inclined me to consider 
it contagious, as I have rarely seen a case in a family of several 
children, which was not followed by others, just as we see in 
rubeola and scarlet fever." He further says: " I do not think 
I have ever seen but one individual have the second attack, 
and that, an individual of peculiar susceptibility to contagion, 
as he has had scarlatina, rubeola, yellow fever, and roseola, each 
a second time." 

It is difificult to account for such a variance of opinion based 
upon clinical experience, but differ as we may upon other points, 
all observers are agreed that the disease is uniformly mild ; that 
it is of short duration, and devoid of complications and sequelae. 
The disappearance of the eruption is not followed by desqua- 
mation. 

Diagnosis. — The appearance of the rash is so nearly like that 
of scarlet fever, and, as we have seen, there is liability of the 
occurrence of an incidental angina, so that the diagnosis will 
often be in doubt for a few hours after the onset of an attack; 
but a short time will suffice to clear up all doubts. The fever 
of roseola rarely lasts over twenty-four hours, while that of 
scarlet fever does not abate or even ameliorate until the subsi- 
dence of the eruption, which ordinarily does not occur until 
after the lapse of several days. In roseola there is wanting the 
characteristic tongue, the mental symptoms and the evidences 
of nervous shock which usually characterize the graver disease. 

Prog7iosis. — This is always favorable. 

Treatment. — Remedial measures are scarcely called for in a 
disease so benign and so devoid of danger as this, but the clin- 
ical fact, which is universally recognized, that the affection is 
dependent on gastric derangement, would suggest the employ- 
ment of such drugs as would restore the normal tone and func- 
tion of the digestive apparatus. In the beginning of the attack, 
the fever may be aborted by aconite and belladonna. 

After one or both of these have been given for a few hours, 
such remedies as arsenicum, nux vomica or laurocerasus may 
be given. The bowels should be opened by warm-water ene- 
mata if necessary, and for a day or two the diet should be 
restricted. 

In many cases of mild type no medication at all will be 
necessary. 



320 



THE DISEASES OF CHILDREN. 



DIFFERENTIAL DIAGNOSIS OF ERUPTIVE FEVERS OF 
CHILDHOOD. 





Measles. 


ROTHELN. 


Scarlatina. 


Roseola. 


Incubation. 


7-12 days. 


7-14 days. 


Few hours to 
seven days. 


None 
perceptible. 


Prodroma. 


3-5 days. 


None. 


None. 


None. 


Initial 
Symptoms. 


Acute 
coryza. 


Fever and 
rash. 


Vomiting, 
fever and rash. 


Fever and 
indigestion. 


Duration. 


9-14 days. 


3-7 days. 


7-42 days. 


A few hours to 
several days. 


Complications. 


Bronchitis, 
pneumonia. 


Scarcely 
anything. 


Acute 

albuminuria 

or Bright's 

disease. 


Gastric 

irritation, 

constipation 

or diarrhea. 


Sequele. 


Eye and ear 
troubles. 


None. 


Almost 
everything. 


None. 


Special 
Symptoms. 


Coarse rash, 

loose cough. 

tongue 

moist and 

white. 


Coarse rash, 
no cough, 
tongue slight- 
ly coated or 
not at all. 


Fine rash, no 
cough, tongue 
heavily coated 
48 hours, then 
reddish raised 
papille. 


Fever, 
vomiting. 


Brain. 


Unaffected. 


UnaiTected. 


Delirium. 




Temperature. 


100O-102O or 
103O 


Rarely over 

1 00° 


102O-107O 


100O-103O 


Skin. 


Sometimes 

slight 

desquamation. 


No 
desquamation. 


Nearly always 
general des- 
quamation. 


Dry and hot. 


Contagious. 


Highly so. 


Moderately so 


Highly so. 


Never. 


Eruption. 


Dull red, 
crescentic. 


Pale, red, 
irregular. 


Bright red, 
diffusely. 


Fine rose- 
colored and 
generally 
local. 


Eruption 
appears first. 


Forehead and 
face. 


Face. 


Face, neck 
and chest. 


Uncertain. 


Eruption — 

extension over 

body. 


3 days. 


2 days. 


2 days. 





DIFFER EN TIA L DIA GNOSIS. 



321 



DIFFERENTIAL DIAGNOSIS OF ERUPTIVE FEVERS OF 
CHILDHOOD. — Continued. 





Measles. 


ROTHKLN. 


Scarlatina. 


Roseola. 


Throat and 
palate. 


Slight 

sore throat, 

dark spots on 

palate. 


Rarely 
affected. 


Always more 
or less sore. 


Uncertain. 


Glands. 


Rarely 
involved. 


Never 
seriously 
affected. 


Generally 

enlarged and 

painful. 


Unaffected 
usually. 


Prognosis, 


Generally 
favorable. 


Always 
favorable. 


Always 
guarded. 


Always good. 



D. C— 21 



CHAPTER VI. 

VARICELLA (CHICKEN-POX). 

Varicella, or as it is more often called, chicken-pox, is the 
mildest of all the eruptive fevers. It is, however, highly con- 
tagious, so that few children escape who are exposed to it. It 
is confined almost wholly to early childhood, and attacks the 
same individual but once. It is quite inclined to be epidemic 
in its nature. West seems inclined to derive the word chicken 
in this connection from the mildness of the disease. It has 
been thought by some to prevail principally before, during or 
after epidemics of small-pox, and hence it was conjectured to be 
a modified form of variola ; hence its name varicella, signifying 
little variola. This idea is not entertained at the present day, 
because clinical experience is opposed to it. It has been found 
that varicella may occur after variola, and variola after vari- 
cella. So that the one is no protection against the other. Be- 
sides, the two diseases are very dissimilar as to duration, gravity, 
and the time of life at which they are most prevalent. 

Varicella is peculiar to infancy and childhood. Dr. J. Lewis 
Smith and Prof. Austin Flint have each observed one case of 
the disease in an adult, but such an occurrence is very rare. 

Moreover, M. Delpech and others have seen varicella and 
variola occur simultaneously in the same individual. The dis- 
ease varies somewhat in the amount of eruption and the inten- 
sity of the attendant symptoms, but it is always mild, and is 
free from complications and sequelae. 

The disease derives its chief interest and importance from 
its liability to be confounded with variola, a mistake which 
has been made, in spite of the great dissimilarity in symptoms 
and course. 

Symptoms. — The constitutional disturbances which mark the 
stage of invasion in varicella are exceedingly variable. In typ- 
ical cases the disease is ushered in by a mild fever, the tem- 
perature rarely going above ioi° Fahr., and the pulse rarely 
exceeding io8 or 112 per minute. 

It is not unusual for the patient to complain of headache, 
languor, chilliness, and sometimes aching in the back or limbs. 
In some cases the fever is entirely absent, or so slight as to es- 
cape notice. The appetite is rarely lost, and there is no inter- 
(322) 



VARICELLA {CHICKEN-POX). 32a 

ruption to the child's amusements. When fever is present it 
usually lasts for twenty-four or thirty-six hours, when the char- 
acteristic eruption makes its appearance. This consists of small, 
scattered papules, which in a few hours become vesicular. This 
rapid vesiculization of the papules is a marked and distinctive 
feature of the disease. The papules are not hard and situated 
on an inflamed base, like those of variola, although they are 
sometimes surrounded by a faint zone of redness. The vesicles 
do not, except very rarely, become umbilicated, and are of 
various sizes and shapes ; some being small, round and acumi- 
nate, while others are large, oval or elongated. The size varies 
from half a line in diameter to two or even three lines. A 
peculiarity of these vesicles is that they appear in successive 
crops, and finally disappear by dessication. 

Sometimes permanent cicatrices are left, but this is generally 
due to the premature rupture of the vesicles by scratching. 
The pruritis is frequently almost intolerable. The eruption of 
varicella is generally in the upper portion of the body, either 
on the back or chest. From whatever part the eruption begins, 
it rapidly extends over the body, the face, scalp and extremities. 
The distribution of the rash is variable. In exceptional cases 
there may not be more than a dozen or twenty vesicles all 
told, w^hile in others the number may mount up into the hun- 
dreds, covering the w-hole cutaneous surface. The eruption, as 
a rule, is most abundant and characteristic on the forehead and 
temples. The vesicles do not tend to become confluent. As 
they mature, many become cloudy, and the contents slightly 
tinged with yellow, from the presence of a few pus cells ; but 
according to Fox, they never become purulent. 

On the second or third day, the eruption begins to decline, 
the vesicles dessicate, some grow tense and burst, or are rup- 
tured by the scratching of the patient, w^hen they form their 
yellowish or brownish crusts. These disappear in a few days, 
leaving small circular patches of reddened skin. 

The eruption affects the mucous membrane as well as the 
skin. The vesicles are thickest on the hard and soft palates^ 
They often form on the prepuce in boys and in the vagina in 
girls, in which case they give rise to much suffering and cause 
trouble in urinating. 

Diagnosis. — The differential diagnosis between varicella and 
variola, is usually quite clear, if the following facts are borne 
in mind : 

The age of the patient. Variola attacks persons regardless 
of age, while varicella is peculiar to infancy and early child- 
hood. The period of invasion is different — that of varicella is 
shorter, wanting altogether, the rash being the first indication 



324 THE DISEASES OF CHILDREN. 

of the presence of the disease. In variola the period of inva- 
sion is three days in duration, and the symptoms of this period 
are well defined. There is a chill, a high fever, vomiting, with 
intense headache and backache. 

These symptoms are never present in varicella. In variola 
the papules do not become vesicular until the sixth or seventh 
day. In varicella, the macules become vesicular in from 
twenty-four to forty-eight hours, and then quickly dry up into 
a light, easily detached crust. In variola, the eruption is most 
abundant on the face, hands and feet, while in varicella, the 
eruption is most profuse on the back. The face, hands and 
feet show but few vesicles. 

The mild and almost insignificant character of the febrile 
stage of varicella is very different from the intense fever which 
attends variola, and in the latter there is a secondary fever 
marking the pustular stage, which is altogether wanting in the 
former. 

In typical cases of the two diseases, there is but little danger 
of confounding them ; but when irregularities occur, as some- 
times happens, the physician will have occasion to exercise the 
greatest care, to avoid falling into error. It will not do to 
decide the question on any one symptom, but the entire cate- 
gory must be weighed separately and together, in order to 
reach the truth. 

The following extract from the writings of Dr. John D. 
Fisher, of Boston, gives an admirable comparative description 
of the two diseases. 

" In most cases the chicken-pox is, by the experienced 
observer, easily and readily distinguished from the small-pox. 
When, however, the former is extraordinarily violent, and the 
latter unusually mild, the distinguishing marks are obscure, 
and the two diseases are therefore frequently confounded. To 
render the distinctions as clear as possible, the more prominent 
symptoms of the two diseases are here contrasted with each 
other. 

'* In small-pox the fever is ushered in by a cold stage, is 
severe and continues three or four days, and if it declines or 
ceases during the eruptive process, it commonly reappears dur- 
ing the suppurative stage, or between the fifth and eighth day 
of the eruption. 

" In chicken-pox the fever is not often preceded by a cold 
stage, is uniformly light and is frequently insensible ; it seldom 
continues more than two days and never reappears after it has 
once ceased. When, however, the vesicles appear in successive 
crops, the fever lasts longer and rages until the eruption is 
completed. 



VARICELLA {CHICKEN-POX). 325 

*' In small-pox the eruption is often preceded or accompanied 
by an erysipelatous efflorescence. 

'' In chicken-pox this efflorescence does not take place. 

" In small-pox the eruption does not break out until the third 
or fourth day of the fever ; it appears first on the face, then on 
the neck, chest, trunk and extremities, and is completed in the 
course of two days. 

" In chicken-pox the eruption breaks out by the termination 
of the first or on the second, and almost invariably before the 
end of the third day of the fever; it usually appears first about 
the breast and shoulders, afterwards on the face and extremi- 
ties. It often, however, follows a different order, and is never 
so uniform in the method of its invasion as the eruption of 
small-pox ; it frequently appears in successive crops for four or 
five days. 

'' In small-pox the eruption presents itself in the form of 
small red circular points or papule ; these are hard, resisting and 
movable, and communicate to the finger a shot-like sensation. 
They scarcely project above the surface, but are easily and dis- 
tinctly felt by drawing the finger over them. 

'* In chicken-pox the eruption likewise breaks out in small 
inflamed spots, but these are not papular in their origin, and 
are not exactly circular, but tend to an oblong figure. They 
may be distinctly felt by the finger, but they are yielding 
under it and are destitute of the tubercular hardness and roll- 
ing motion which characterize the variolous eruption at the 
same period. 

" In small-pox the eruption seldom becomes vesicular be- 
fore the end of the second or the commencement of the 
third day, and the vesicles are confined to the summits of 
the pocks. 

" In chicken-pox the eruption is vesicular from the begin- 
ning, or from the early part of the first day, and by the second 
day the whole surface of the pocks are converted into vesicles 
which resemble little bladders of transparent fluid. 

'* In small-pox the pustules at first have acuminated sum- 
mits ; they afterwards become rounded, and at an early period 
present slight depressions in the center of their surfaces. 

" In chicken-pox the vesicles are usually lenticular in form, 
but are sometimes conoidal or globate, and preserve one shape 
through their course, or until they become ruptured. 

" In small-pox the eruption is situated in the substance of 
the cutis, as has been proved by dissection, and as is evident 
from the sensation which the pustules communicate to the 
finger. 

" In chicken-pox the vesicles are not formed in the true skin, 



326 THE DISEASES OF CHILDREN. 

but are situated upon its surface in the cellular tissue between 
the skin and cutis. 

*' In small-pox the pustules after they have become vesicular 
are distinguished by hard, unyielding bases. 

" In chicken-pox the vesicles are destitute of such tubercular 
basis. They are yielding and easily give way under pressure, 
and communicate to the finger a soft, elastic sensation, or a 
feeling similar to that which a minute globule of fine sponge 
softened with water would give rise to when pressed. 

'' In small-pox the pustules are composed of little cells, all of 
which, however, communicate with each other ; and the cuti- 
cular covering of the pocks is opaque, tough and not easily 
broken. 

" In chicken-pox the vesicles are composed of a single cavity, 
and the coverings are extremely thin and fragile, are diapha- 
nous and are very easily broken. 

*' In small-pox the pustules are, at an early stage, filled with 
a serous secretion ; this, after a time, becomes converted into a 
purulent matter that exhales a very unpleasant and peculiar 
odor. 

** In chicken-pox the vesicles contain, when fully matured, 
only a whitish, transparent and serous fluid ; this never, except 
through accident, becomes pus, and is destitute of any ungrate- 
ful odor. 

" In small-pox the pustules remain whole till they are six or 
seven days old, when some of them commonly become rup- 
tured, and permit a little of the virus to ooze out upon their 
surface ; but they still retain their form and prominency. 

" In chicken-pox the vesicles often become broken in two or 
three days after their appearance, and permit the whole of their 
contents to escape. Their coverings then sink down and col- 
lapse, and the vesicles become flattened and lose their original 
form. 

" In small-pox the pustules break out simultaneously, pur- 
sue a regular march and arrive at maturity at about the same 
time. 

" In chicken-pox the vesicles generally break out in succes- 
sive crops for a number of days, in which case a great variety 
may be observed among them ; some are appearing, whilst 
others are fully formed, shriveled or crusted. 

'' In small-pox desiccation does not commence till about the 
.eighth day from the appearance of the eruption. 

" In chicken-pox, when the vesicles run their course without 
bursting, desiccation commences in them as early as the fifth 
day of their age, but it always begins as soon as the vesicles 
are ruptured, and consequently it more usually commences on 



VARICELLA {CHICKEN-POX). 327 

the third or fourth day, and sometimes as early as the second 
day after they appear. 

" In small-pox the processes of eruption, of suppuration and 
of desiccation constitute three successive periods, rendered 
distinct from each other by their duration ; the first occupies 
about three days and the other two about five days each. 

" In chicken-pox these three periods seem to be confounded 
in consequence of the pocks appearing in successive crops, and 
even when they are distinguishable, the sum of their duration 
seldom exceeds eight days. 

" In small-pox the scabs fall off in a single piece. 

" In chicken-pox the scabs do not usually fall off in a single 
piece, but in small fragments of different forms and sizes. 

" The small-pox, even when distinct and of moderate mild- 
ness, is a disease of fifteen or twenty days in duration, and it 
often proves fatal. 

'* The chicken-pox, on the contrary, runs its course and is 
completed in five or six days, or in eight or ten at most, and it 
never, of itself, proves fatal. 

" The distinctions between the chicken-pox and the varioloid 
disease, or the small-pox in its modified form, are less striking, 
and less easily recognized. The following peculiarities, how- 
ever, may generally be observed in the two diseases, and will, 
in most cases, lead to a correct discrimination. 

" The chicken-pox, as has already been stated, is distinguished 
by the eruptive fever being generally light. 

'* In the varioloid disease the precursory fever is commonly 
sharp and of several days' duration. 

" In chicken-pox the eruption appears in the form of vesicles, 
or it is vesicular, at least, from an early period of the first day. 

" In the varioloid disease the eruption is always papular in 
its origin, and seldom becomes vesicular before the second or 
third day. It appears all at once and seldom breaks out in 
successive crops. The pocks are, in the first instance, elevated 
on solid tubercular bases, and their tops are resisting and not 
easily broken. The eruption, as in the unmodified variola, is 
formed in the substance of the true skin, as is evident from 
the hard and elevated bases which remain after the lymph is 
removed from the pustules by puncture and pressure, and by 
the kernels or tubercular elevations which remain in the skin 
after the scabs have fallen off. The pocks from their first 
formation are hard and unyielding, and are movable and rolling 
under the finger." 

To these distinguishing characteristics, all of which have 
been noticed by various writers, the author would add the fol- 
lowing : 



328 THE DISEASES OF CHILDREN. 

" In chicken-pox, if, during the first day of the eruption, the 
parts on which it exists be embraced with the thumb and finger 
and gently distended by them ; or if a single finger be drawn 
over them with a force just sufficient to cause the little ruge of 
the cuticle to become smooth, the inflamed spots, in which 
form the vesicles first present themselves, readily disappear and 
leave no discoloration or induration in the skin. 

" In the varioloid disease, if a hke distention of the parts 
occupied by the eruption be made at the same date, the in- 
flamed spots disappear less readily and, even when the distend- 
ing force is sufficiently great to make them disappear, a dim 
discoloration can be perceived and a distinct shot-like hardness 
may be felt at the points upon which they were planted. 

" In chicken-pox the scars left in the skin after desquamation 
are destitute of any peculiar hardness, and are, in the space of a 
few days, entirely erased. 

*' In the varioloid disease the eruption, for a considerable 
time after the scabs have fallen, leaves little kernels, or tuber- 
cular elevations, in the skin. The varioloid disease has the 
power of communicating the unmodified and modified small- 
pox." 

In addition to a careful study of these distinguishing feat- 
ures, the physician should ascertain if the patient has been 
sucessfully vaccinated within five years ; if so, the probability is 
in favor of varicella, particularly if the subject is a child, as 
varicella rarely affects an adult. 

Treatment. — The treatment of varicella does not call for any 
extended comment. Ordinary cases will not require any treats 
ment. There is no known prophylactic. The disease will run 
its usual and discreet course, whatever is done or left undone. 

VACCINIA — VACCINATION. 

Vaccinia is a mild eruptive fever produced by vaccination for 
the purpose of protecting the subject from the graver disease, 
small-pox. It is communicable only by contact, and is not con- 
tagious through the air like the other eruptive fevers. 

It is inoculable by the lymph contained in the vesicle, and also 
by the moistened scab which results from the dessication of the 
pustule. 

Vaccination has now everywhere taken the place of inoculation, 
which was the first step which scientific medicine took to stamp 
out that most dreaded of all diseases, small-pox. For fifty years 
— the latter half of the eighteenth century — inoculation was 
practiced both in Europe and in this country, but so many 
deaths and so much indirect suffering occurred as the result of 



VA C CINIA— X 'A C CINA TION. 329 

this method, that it began to be looked upon with distrust. 
The efficacy of the operation in mitigating the severity and 
danger from small-pox was certainly very great, for the propor- 
tion of deaths following it was, on an average, only about three 
in a thousand — a very gratifying contrast to the mortality of 
the disease communicated in the usual way. *' But there was 
one fatal drawback. However light the engrafted disease might 
be, it was still small-pox ; and the more it was conveyed in this 
way, the more were centers of infection multiplied, from which 
those not protected were liable to contract the disease in its 
worst form. To individuals, inoculation was a great blessing ; 
to society at large, it was a great curse. In the early part of 
the eighteenth century, before inoculation, about one-four- 
teenth of the deaths in Great Britain were from small-pox ; in 
the latter part, after inoculation had become quite general, 
about one-tenth of the deaths were from that disorder." "^ It 
was at this time (1796), when inoculation as a preventive of 
small-pox, had received general recognition, but not general 
adoption, for reasons already stated, that Jenner demonstrated 
the great and immortal fact, that by passing the small-pox 
virus through one of the lower animals, especially the cow, it 
could be so modified as to lose its contagious properties and 
yet, when inoculated, thus modified, into the human system, it 
afforded all the protection which resulted from the use of the 
genuine virus. 

Vaccination, then, is the conveyance of small-pox into the 
system of a susceptible human being, but of a small-pox 
wonderfully modified, and shorn of its terrors, by previously 
passing it through an animal. 

In the process of transmission through a lower animal organ- 
ism, it has in some way, parted with its contagious property, so 
that vaccinated small-pox, thus modified, is not constantly 
spreading the disease as was the case with inoculated small-pox. 
Jenner demonstrated that the horse as well as the cow could 
be made the subject of variolous infection, a fact that has been 
repeatedly verified since his day. At present, however, the 
cow is practically the only source of original supply of vaccine 
virus ; indeed, the term vaccination is derived from " vacca,'' '' a 
cow." 

No other discovery in the whole history of medicine com- 
pares with that of Jenner, in relieving human suffering and 
saving human life ; and if vaccination were only universally 
employed, there is every reason to believe that small-pox would 
be wiped from the face of the earth. In Chicago there is a 



* Dr. W. T. Plant, in " Cyclopedia of Diseases of Children.' 



330 THE DISEASES OF CHILDREN. 

constant inspection of all the pupils attending the public 
schools, and no child is permitted to attend school without a 
certificate, showing recent vaccination. During the year end- 
ing December 31, 1892, small-pox made its appearance five 
times, but in every instance the source of contagion was traced 
to foreign countries, and in a population of 1,250,000 people, 
there were, during this year, but two deaths from small-pox. 
The opponents of vaccination need no other answer than to 
contrast this almost complete exemption with the annual 
mortality from this disease in all countries one hundred 
years ago. 

TJie Virus. — Until a comparatively recent period, the source 
of supply of fresh animal virus was so uncertain and precarious 
that the custom prevailed of using lymph from the human sub- 
ject, and thus transmitting the vaccine disease from one person 
to another. 

But the danger of inoculating healthy persons with constitu- 
tional taints, such as struma, psora, and syphilis, came to be 
regarded as so great that of late years this source of supply has 
been nearly abandoned. Besides, it is believed that the virus 
thus procured, after many transmissions, becomes so attenuated 
as to be of uncertain efficacy. For these reasons it is now the 
general custom to use only bovine virus, procured directly from 
the cow. In order to keep up a uniform and reliable supply 
of this virus, there have been established numerous ''vaccine 
farms," in different parts of the country, where young heifers 
are constantly subjected to the process of propagation. From 
these " farms," or vaccine establishments, the lymph is distrib- 
uted by mail or express as needed, to all parts of the world. 

The virus is dispensed either in the form of scabs, or on 
ivory points that have been dipped in the fresh lymph of a 
punctured vesicle. The latter is decidedly the more preferable, 
as the ivory point makes an admirable vaccinator. 

It should be borne in mind that vaccine virus, whatever be 
its source, is very perishable, and soon loses its efficacy if ex- 
posed to light, air, warmth, or moisture. Cold does not affect 
it, and with proper precautions it may be kept indefinitely. 

Vaccination. — Vaccination is the slight surgical operation 
necessary to insert the virus, and consists in getting an abraded 
or denuded surface of small area, on v/hich the moist virus is 
placed and allowed to dry. 

The exact site where the vaccination is to be performed is 
optional, but generally the arm or leg is selected. If the former, 
the outer aspect of the left arm is preferred, at or near the 
insertion of the deltoid muscle. With females we prefer to use 
the leg — it matters not which — for the reason that in a certain 



VA C CINIA — VA C CINA TION. 331 

proportion of vaccinations, no matter how fresh and pure the 
virus nor what amount of care is exercised in the operation, an 
excessive amount of inflammation and suppuration will ensue 
and in consequence a scar will result which on the arm will 
ever after be an unsightly blemish. Even with boys we prefer 
the leg, on account of the greater facility with which it can be 
inspected and if necessary, treated. 

When the leg is chosen for the operation, the virus should 
be inserted at about the outer edge of the gastrocnemius mus- 
cle, midway of its length. 

The ordinary instrument used for vaccination — when a 
special instrument is used at all — is the common lancet. This 
should be perfectly clean, and care should be taken not to 
draw blood, if possible. 

The epidermis may be scraped until the cutis is exposed and 
a little serum exudes. This scraping should be over a surface 
from a quarter to half an inch square. On this abraded sur- 
face the virus, moistened just enough to " revive," is placed 
and allowed to dry. It is never best to cover the wound 
with plaster or bandage immediately after the operation, for 
the reason that either is liable to absorb the lymph before the 
skin is able to do so. 

A better method than that just described is to scarify the 
necessary surface with the ivory point, which is made sharp at 
the charged end expressly for this purpose. A dozen or 
twenty linear incisions should be made, all quite superficial, 
and from half a line to a line apart ; then as many cross inci- 
sions should be made in like manner, after the manner of a 
checker board. If some blood is drawn, as is most always the 
case, it should be wiped up with a clean cloth or a blotter. 
The ivory point, slightly moistened in cold water, should then 
be rubbed over the surface and the moisture allowed to dry as 
before. 

Painless Vaccination. — Whichever of the foregoing meth- 
ods is chosen, there is some pain, or at least some discomfort 
with it. Some children are much more susceptible to pain 
than others. Few parents like to see their infants hurt, and to 
the onlooker the operation of scraping or scarifying the delicate 
skin of a young infant seems a barbarous procedure. 

All of this can be avoided if the physician will but take the 
trouble, and the vaccination can be successfully done while the 
child is peacefully slumbering. The author does not know to 
whom he is indebted for this painless method, but he has em- 
ployed it for many years past and in scores, if not in hundreds, 
of cases. It is believed to be a superior method, not alone 



332 THE DISEASES OF CHILDREN. 

because it saves suffering, but because it is more uniformly- 
successful in results than any other. 

The plan is to apply to the arm or leg of the child, a few 
hours before the operation — say the night previous — a piece of 
adhesive plaster an inch square, in the center of which has 
been placed a mere dot of Spanish-fly blister. The fly oint- 
ment should be used, as the powder deteriorates very rapidly, 
and care should be taken that the ointment is fresh or disap- 
pointment will ensue. After the lapse of a few hours, the piece 
of plaster is to be carefully removed, and a small blister will be 
found on the site of the cantharides. This should be punc- 
tured and the serum let out, and on this denuded surface of the 
cutis vera the virus is placed, just as in the other methods. 
Care must be taken not to make too large a blister. The 
amount of cantharides should be the smallest possible — the 
merest dot — less in size than the head of an ordinary pin. 

Sympt07ns and Course. — For a period varying from three 
days to a week there are no visible or perceptible phenomena. 
The virus is in process of incubation. On the third or fourth 
day a small, hard papule makes its appearance at the point of 
operation. In the course of twenty-four or forty-eight hours 
this papule becomes a vesicle, and in another day it has be- 
come umbilicated and divided into eight or ten cells or com- 
partments — in this respect acting precisely like the genuine 
small-pox vesicle. By the eighth or ninth day after the opera- 
tion the vesicle has matured and attained its complete develop- 
ment. It is raised prominently above the surface and is dis- 
tended with transparent fluid. This fluid is the lymph used 
for subsequent vaccinations where human virus is employed. 

When desired for this purpose, the vesicle should be punc- 
tured — never later than the ninth day — and carefully preserved 
in a cool place, unless used immediately. At this time, a belt 
of inflammatory redness forms about the base of the vesicle, or 
pustule, as it has now become. This is the characteristic areola, 
which indicates successful vaccination. For several days the 
areola widens until it attains a diameter of two or three inches^ 
There is now considerable induration ; the flesh is hard, hot, 
itchy and painful. As these phenomena develop, there are con- 
stitutional symptoms evolved, such as fever, headache, rigors 
and general aching. The member operated on is apt to be 
lame and painful. Not infrequently the axillary or inguinal 
glands become swollen and tender. This state of affairs is of 
short duration. After the tenth day all inflammatory symptoms 
decline, and the constitutional disturbance abates. The local 
pain, the itching and the swelling rapidly decrease ; the areola 
fades away ; the fluid in the vesicle loses its translucence and 



VA C CINIA — VA C CIA' A TION. 333 

speedily dries down into a hard, dark crust, which falls off about 
the twenty-first day, leaving a circular, depressed scar, at first 
red, but soon pale, which commonly lasts through life. 

Dcviatio7is and Complications. — While vaccination ordi- 
narily runs a regular course, one phenomenon following another 
in systematic order, this is not always so, and deviations from 
the rule are sometimes met with, for which the physician is un- 
justly blamed. The cases where vaccinia produces more 
than temporary illness, as above described, are rare, and when 
eczema or erysipelas supervenes, or extensive suppuration 
occurs, it is generally attributable to a constitutional defect in 
the child, rather than to the impurity of the vaccine virus, or 
an illy performed vaccination. It is quite possible for diseases 
and tendencies, that have been hitherto latent, to be stirred 
into activity by this operation, but surely, in such cases, the 
unexpected results should not be charged to the operation 
itself, which, as a rule, is so free from danger and so benign in 
its effects. 

The question is often asked, as to the degree and duration of 
the protection against small-pox, which is afforded by vaccina- 
tion. There have been exceptional cases recorded, in which 
vaccinated persons have contracted variola, notwithstanding 
they could show a characteristic scar. In such cases the immu- 
nity is only partial, and a modified small-pox is possible. Dr. 
Buchanan, of London, has carefully compiled statistics of 
deaths from variola among the vaccinated and the unvaccinated, 
from which it appears that the death rate from small-pox, 
among those who were vaccinated in infancy, is 40 per million, 
while the death rate from this cause among the unvaccinated is 
5.950. 

Among those vaccinated in infancy or early childhood, there 
is undoubtedly a tendency to outgrow the protective virtues of 
the operation. There is a general impression that such vacci- 
nations should be repeated after puberty is passed. Dr. Martin 
is quoted as saying that he has succeeded in re-vaccinating with 
bovine virus in seventy-three per cent, of the cases in which he 
has tried it. In case of exposure, re-vaccination should be 
performed, unless a prior vaccination has been successful within 
five or six years, whether in child or adult. 

It occasionally happens that a child is vaccinated one or 
more times without typical results. In such cases the fault is 
presumably the fault of the virus or the operator rather than 
the subject. It is believed that susceptibility to vaccinia is 
universal and without exception. Dr. Plant is authority for the 
statement that of upwards of nine thousand operations done at 
the Blackfriars Station of the National Vaccine Establishment 



334 THE DISEASES OF CHILDREN. 

since 1859, there was but one single case, which on a second 
trial was unsuccessful. There may be cases in which for a time 
the system may have lost its susceptibility, as when pre-occu- 
pied by some other disease or perturbation ; but this is undoubt- 
edly only for a limited time and in a very limited number of 
individuals. It is hardly possible for it to extend over a life- 
time in the face of so much opposite experience. 

The age at which vaccination should be performed is worthy 
of a moment's consideration. Nearly all countries require that 
it be done before the end of the first year. In England, the 
Vaccination Act of 1867, requires the operation to be per- 
formed "within three months of birth, or as soon afterwards as 
the public arrangements of the district in which the family 
lives will afford opportunity of obtaining gratuitous vaccina- 
tion." It should be done in all cases before dentition begins 
or between the first and fourth months. In case the child is 
out of health or has any skin eruption, it should be got in good 
condition before the operation. 

In case small-pox is prevailing in the vicinity, there is no 
reason for postponement either on account of age or bad phys- 
ical condition. 

Wolff {Berl. Klin. Woc/i., No. 17, 1889), reports the vaccina- 
tion of eight new-born infants, one of two days old, with 
humanized lymph, and has observed in them the normal devel- 
opment of the pustule, with a complete absence of the vaccine 
fever. An equally good result was observed in thirty-four other 
new-born infants, in ten of which the mothers were vaccinated 
immediately before birth. Fifteen newborn infants were inoc- 
ulated with animal lymph, and quite as many were successful 
as is the case in older children. The only point of remark in 
the two sets of inoculation was the much higher maximum of 
temperature reached in the cases in which animal virus was 
used. The author concludes that new-born infants are equally 
susceptible with older children to vaccination ; that the opera- 
tion is attended with no danger, and that in times of variola 
epidemics the new-born babes should be vaccinated without 
delay. 

The season of year seems to have no special bearing on 
the subject. In summer and winter the course of vaccinia 
is the same. An unprotected infant, no matter hov/ young, 
who is about to travel in a public conveyance should always be 
vaccinated before starting. 

After Treatment. — Although in any case the amount of 
suffering attendant on vaccinia is but trifling, when compared 
to that of the horrible disease which it seeks to prevent, still 
there are cases where the pruritis is very distressing, and where 



VA C CIXIA — VA C CINA TI ON. 335 

the amount of inflammation exceeds the ordinary boundaries and 
some means of alleviation are called for. In the case of young 
children, the desire to relieve the itching by scratching is al- 
most uncontrollable, and there is danger of interfering with the 
integrity and completeness of the process, if this be permitted. 
To avoid it, the vaccination should be covered with a dossil of 
lint wet with olive oil and held in place with a few turns of a 
bandage, the ends of which should be secured by a few stitches. 
If there is considerable local fever, with swelling and tender- 
ness, much relief will be given by the occasional application of 
dilute Goulard's lotion (sub-acetate of lead, one part to ten of 
water). Still better is witch hazel (hamamelis). 

In cases of exceptional violence, tending to gangrene, erysip- 
elas, or septicemia, active measures, both medicinal and local, 
should be used, just as if the same condition had resulted from 
other causes. 



PART Vl. 

NON-ERUPTIVE CONTAGIOUS DISEASES. 



CHAPTER I. 

DIPHTHERIA. 

Definition. — Diphtheria is an acute, specific and highly dan- 
gerous affection, the principal local manifestations of which 
consist in the formation of more or less extensive patches of 
pseudo-membrane upon and within the mucous surfaces of the 
pharynx, larynx and nose. Occasionally it affects other sur- 
faces. It is inoculable, infectious and contagious, and is both 
endemic and epidemic. Nearly all authorities are agreed that 
frequently it occurs sporadically. Most cases are attended with 
swelling of the cervical glands. Clinically, the disease is 
marked by great constitutional weakness, by irregular fever of 
low type ; frequent albuminuria ; by tedious and uncertain 
convalescence; by a tendency to toxemia which may result in 
heart failure ; and by peculiar paralytic sequele. 

It is by no means a new disease. As far back as medical 
records go, we find described a disease of the throat and upper- 
air passages, so strikingly like that which we now call diph- 
theria, that their identity is indisputable. 

Sir Morell McKenzie, in his " Treatise on the Diseases of 
the Throat and Nose," says : ** Centuries before the time of 
Hippocrates, an Indian writer had included in his System of 
Medicine, a description of a disease, entirely analagous to the 
one under consideration. This work was originally written in 
Sanskrit, but a Latin translation was made of it by F. Hessler, 
and published in 1844, a copy being in the British Museum. 
The writer says the disease is characterized by an increase of 
phlegm and blood which causes a swelling in the throat, 
attended with pain and panting, destroying the vital organs 
and incurable. He also says : 'A large swelling in the throat, 
impeding food and drink, and marked by violent feverish symp- 
toms, obstructing the passage of the breath, arising from 
phlegm combined with blood, is called '* closing of the throat." * 
(336) 



DIPH THERIA . 337 

All of the older writers, whose works have been preserved, 
describe in varying language a similar disease and note the ter- 
rible mortality attending it. Asclepiades is always cited in this 
connection as being the first to perform laryngotomy. Are- 
teus of Cappadocia, Galen, Celius Aurebianus and other 
contemporaneous writers describe it. In the fifth century Aetius 
advised against energetic local treatment and the forcible 
removal of the deposits before they were in a condition to fall 
off spontaneously." During the dark ages the record is broken, 
and during the middle ages only references are made to it in 
connection with gangrene. In this country it appeared as early 
as the seventeenth century, at Roxbury, Mass. 

Samuel Danforth, a graduate of Harvard University, had, in 
1643, twelve children. His first child died at the age of six 
months. According to his biographer, John Langdon Sibley, 
" the next three, being attacked by the * malady of bladders in 
the windpipe,' in December, 1659, it pleased God to take them 
all away at once, even in one fortnight's time." 

During the following century of our colonial history, occa- 
sional reference is made to its devastations, especially in Massa- 
chusetts, New Jersey and New York. In 1735, the disease 
appeared in epidemic form at Kingston, N. H., a small inland 
town some fifty miles eastward of Boston. Dr. Wm. Douglas, 
at that time a prominent physician of Boston, has given a most 
graphic description of the disease and its ravages. He called 
it " putrid sore throat." He says : 

" It was first noticed in Kingston township, on the 20th of 
March, 1735. As this was an inland place of no considerable 
trade or importance, it was thought (incorrectly, perhaps) to be 
of indigenous origin, and not of foreign importation. The 
first victim was a child, who died in three days; and about a 
week after three children were seized in another family, four 
miles distant, and they also died on the third day. It continued 
spreading gradually, seizing here and there particular families, 
with that degree of violence that of the first forty cases none 
recovered. Some of the patients died of a sudden, acute necro- 
sis, or mortification ; but most of them were carried off by a 
sympathetic affection of the fauces, neck or air-passages ; or by 
an infiltration and tumefaction of the chops, and forepart of the 
neck, which became so enlarged and turgid, as to bring upon a 
level all parts between the chin and sternum, occasioning a 
strangulation of the patient in a very short time. After a few 
weeks it spread from Kingston to the neighboring townships, 
but in a milder form. No reason could be given for this greater 
malignity in Kingston, except, perhaps, the prevalence of damp 
places near large ponds, and fresh water, but sluggish streams, 
D. C— 22 



338 THE DISEASES OF CHILDREN. 

like in those localities which produce the rot in sheep. There 
may also have been bad medical treatment. Its first recog- 
nized appearance in Boston was on the 20th of August, 1735, 
in a child . . . who had white specks in the throat, and a 
cutaneous efflorescence. A few more . . . were seized in 
like manner. Towards the end of September it appeared in 
several parts of the town of Boston, with more decided com- 
plaint of soreness of the throat. The tonsils were swelled and 
specked ; the uvula was relaxed ; there was slight fever, and an 
erysipelas or scarlet-fever-like efflorescence on the neck, chest, 
and extremities. The first alarming case was in the beginning 
of October, in a young man. He had lately arrived from 
Exeter, to the eastward of Boston, where his brother had died 
of the same illness. His symptoms were great prostration of 
strength, a single speck on one of his tonsils, and colliquative 
sweats . . . It increased during the winter up to the second 
week in March, 1736; when it was at its height, there being 
twenty-four burials in all, during the week (instead of nine or 
ten). . . . The disease was so much milder in Boston than 
in some of the townships where it first prevailed, that many 
could not be persuaded that it was the same disorder. . . . 
To the eastward of Boston, at times, one in three died, in other 
places one in four, and in scarce any towns, less than one in 
six ; whereas in Boston not above one in thirty-five succumbed." 

Belknap, in his " History of New Hampshire," states that in 
that province, not less than one thousand persons died of the 
disease, of whom nine hundred were under twenty years of age. 

Dr. Kearsley, an eminent physician of Philadelphia, writing 
about the same time, gives an affecting account of its devasta- 
tions, as he witnessed them. '' Like most new diseases," he 
says, " till their constitution and nature are known, it swept all 
before it ; it baffled every attempt to stop its progress, and 
seemed by its dire effects to be more like the drawn sword of 
vengeance to stop the growth of the colonies than the natural 
progress of disease. In the New England governments the 
stroke was felt with the greatest severity ; villages were almost 
depopulated, and parents were left to bewail the loss of their 
tender offspring, till heaven, at last, the only unerring physi- 
cian, was pleased to check its baneful influence." 

From this early appearance of the disease in this country it 
has never been entirely absent. A few isolated towns and 
hamlets may have escaped its invasion, but in the larger cities 
it is endemic, and the rural districts are rare in which it has 
not at some time been epidemic. 

The name by which we know the disease and which was 
given it by the registrar-general of England some fifteen years 



DIPHTHERIA— E TIOL OCT. 339 

ago, is the only new feature about it at the present day. Pre- 
viously it had been known by so many different appellations 
that an entire page would be necessary to enumerate them. 
As diphtheria (meaning, to resemble wash leather), it is now 
known in all civilized countries. 

Etiology. — Diphtheria is essentially a disease of childhood, 
and most common before the age of puberty. Nine-tenths of 
its recorded victims are under twenty years of age. In this 
respect it does not differ, at the present day, from the mortality 
ascribed to it on its first appearance in New England. Sex 
does not seem to influence it. 

It is far more common in the fall and spring — the season of 
colds — than in mid-summer and mid-winter. Sudden changes 
of temperature favor it, whether in summer or winter. It is 
more prevalent in northern than in southern latitudes, although 
no place is known to be entirely exempt from it. Other affec- 
tions of the throat, such as tonsilitis, laryngitis, pharyngitis and 
quinsy, are very commonly associated with it. It is apt to 
follow or accompany epidemics of measles and scarlatina. 

Its contagiousness is everywhere recognized. And yet prop- 
agation by direct contagium fails to account for the vast 
majority of cases, whether occurring in isolation or in epidemics. 
Fifty different epidemics of diphtheria, occurring in various 
localities in England, were recently investigated with great 
care, and in only four could the outbreak be traced to direct 
contagion. The rest were all connected, according to Dr. W. 
Gilman Thompson, "^^ with foul cess-pools, deficient drainage, 
sewerage, or the proximity of dirty animals and decomposing 
organic matter, such as manure." That unsanitary conditions 
favor its development and increase its malignancy, goes with- 
out saying; but it cannot, however, be considered as essentially 
a filth-disease. We have seen fatal cases, both in this city and 
neigboring villages, in houses that were new, and where every 
sanitary safeguard had been intelligently utilized. 

Some twelve years ago the trustees of the Newberry estate 
erected a block of dwellings on the principal avenue of the 
north division of Chicago. This avenue was thorough sewered. 
The foundations of the houses were on sandy soil. The base- 
ment story of each was mainly above grade. The houses them- 
selves were of pressed brick, and no expense was spared in their 
construction. The plumbing throughout was the best that 
could be had. Money, science and skill were lavished upon 
them to make them the most desirable tenement homes in the 
city. 



♦ See "American Text-Book of Theory and Practice of Medicine," Pepper, 1893. 



340 THE DISEASES OF CHILDREN. 

Among the first of the tenants was a wealthy banker with 
his wife and one child, some two years old. The latter was a 
robust, healthy boy who had scarcely suffered a day's illness in 
his life. But before the family had lived in this new house a 
year, the child was taken ill with diphtheria and died after a 
week's sickness. For a month prior to his illness he had not 
been out of the house, owing to the inclemency of the weather. 
At the time of his death there was not and had not been a 
case of diphtheria in the neighborhood, and during that season 
there was less than the usual amount of the disease in the city. 
Neither before nor since has there been a serious case of acute 
illness in the entire block of seven houses. 

It would be difificult to defend the theory of filth causation 
in a case like this. But this is by no means an exceptional 
one. The writer could instance numerous cases equally in 
point, and doubtless most physicians in active general prac- 
tice could do the same. It is a noteworthy fact in connection 
with the case just cited that the parents of the child had pre- 
viously lost two children from the same disease and at about 
the same age. And this brings us to consider the first of the 
causes which predispose to the disease, namely, susceptibility. 
It is a matter of common observation that certain families are 
more prone than others to all forms of throat disease, includ- 
ing diphtheria. Many families seem to possess a complete 
immunity from tonsilitis, pharyngitis and throat affections gen- 
erally ; while others, equally well apparently in other respects, 
are continually under treatment for some trouble of the throat. 
The slightest cold, or even a trifling indigestion, congests the 
tonsils or produces a local catarrh or inflammation. Such 
persons are very liable to have diphtheria. 

Another of the predisposing causes of diphtheria is age. As 
already stated, nine-tenths of the mortality from this disease 
occurs in childhood. All statistics thus far compiled show 
that the greatest mortality occurs under twelve years of age. 
After this period the susceptibility gradually diminishes until 
maturity is reached. In adult life the disease is usually much 
milder in form and markedly less fatal, although deaths from 
diphtheria have been known to occur at all ages. While 
rare in early infancy, Eichhorst and others have known it to 
be acquired by the new-born. A case well illustrating the 
usual non-susceptibility of infants is recorded by Dr. J. S. 
Mitchell. "A lady, aged twenty years, nursing her first child, 
was under my charge for a severe case of pharyngeal diphtheria. 
The attack was one of uncommon severity, approaching the 
malignant type. Her baby nursed regularly throughout the 
attack, and escaped any sign of the affection." 



DIPHTHERIA— SEASON OF 7'EAR. 



341 



Season of Year. — Epidemics of diphtheria have been known 
at all seasons of the year, but it is greatly favored by cold and 
dampness. Where these two conditions are conjoined, diph- 
theria is sure to prevail. The mortality in this city from this 
disease during last year (1892), by months is typical. The 
mortality for ten or any number of years would show the same 
relative ratio : 



Jan. 


Feb. 


Mar. 


Apr. 


May 


June 


July 


Aug. 

49 


Sept. 


Oct. 

iiS 


Nov. 


Dec. 


117 


So 


91 


62 


70 


51 


32 


57 


136 


151 



But of all the causes predisposing to diphtheria, the foremost 
one is cold. Children are proverbially sensitive to atmospheric 
changes. They are very prone to hypertrophic catarrhs. Their 
tonsils are large and very subject to acute inflammation, as is 
also the whole respiratory tract. The lymphatic system is very 
subject to disturbance and to nothing sooner than to the effects 
of cold. An epidemic of diphtheria occurring at Fort Atkinson, 
a small town in Wisconsin, in the summer of 1885, well illus- 
trates not only how sporadic cases sometimes originate, but 
also how a sporadic case may start an epidemic of indefinite 
proportions. 

In June of this year (1885), a lad of thirteen took cold from 
bathing in the river, which runs through the town, and the next 
day had a sore throat, fever and headache. He had epistaxis 
several times during the subsequent two days, but he was not 
regarded as sick enough to call a doctor, and the exact condi- 
tion of his throat is not recorded. Five days later, an infant of 
eighteen months old was taken sick with fever and sore throat, 
and speedily developed a well-defined case of pharyngeal diph- 
theria, from which it died after an illness of four days. On the 
day of its death a boy, aged seven, in the same family, was 
taken sick and died after an illness of three days. During the 
two weeks subsequent to the illness of the first case, there were 
ten cases in the immediate neighborhood, with four deaths, 
showing a mortality of forty per cent. As soon as the disease 
was recognized as diphtheria, the most rigid quarantine was es- 
tablished. The public school was closed ; all social gatherings 
were abandoned, and the infected families were isolated from 
their neighbors. In this way the epidemic — for such it was in 
a small way — was restricted to a single row of houses on the 
one business street of the small town. 

Previous to the outbreak of which we are writing, there had 
been but one single case of diphtheria known in the township, 



342 THE DISEASES OF CHILDREN. 

and that was some six miles distant and four months earlier. 
An old physician who had practiced there for over forty years, 
told me that he had never seen a case of diphtheria in his life. 

Instances by the score might be cited where seemingly an 
ordinary cold, in no way differing in subjective or in objective 
symptoms from similar colds taken before, have in a given case 
communicated genuine diphtheria to a susceptible — and usually 
younger — subject, with fatal results. So often has this hap- 
pened in our personal experience that we isolate, so far as prac- 
ticable, all cases of tonsilitis or sore throat attended with 
exudation or foulness of breath. We regard this as absolutely 
essential where a sore throat develops in an adult in a family 
where there are young children. 

It should be borne in mind that adults have diphtheria, as a 
rule, in a much milder form than children, and it is often diffi- 
cult, if not impossible, to distinguish an innocent and non-con- 
tagious sore throat from one capable of communicating a 
veritable diphtheria to a susceptible child. A person with a 
sore throat, of whatever character, no matter how simple and 
innocent it may appear, should never kiss or fondle a child, if 
it is possible to avoid it. The following case, occurring some 
years ago, is in point. Mr. G. had just returned to his home 
from a trip east, and, as he supposed, took cold in the sleeping 
car. The next day I was sent for and found him suffering 
from a mild attack of follicular tonsilitis ; at all events it had 
this appearance and nothing more. He had some fever and 
complained of headache and chilliness. There were perhaps 
half a dozen spots or patches of exudate on the tonsils which 
could easily be wiped off with a pledget. There was some 
dysphagia and the pharynx and uvula were inflamed. He 
made light of his illness and said he had had a similar sore 
throat scores of times before. In spite of this I cautioned him 
about caressing his six-year-old son, who was playing about, 
and of whom I noticed he was very fond. I treated the case 
for a couple of days, when I dismissed him, and two days 
thereafter I met him down town feeling as well as ever. In 
less than a week I was called to see this only child, above men- 
tioned, who suddenly developed a most malignant case of diph- 
theria and he died after an illness of five days. 

It cannot be too strongly insisted upon that a catarrhal inflam- 
mation, wherever located, or however produced, may become 
diphtheritic and pseudo-membranous. This is in harmony 
with the observation made by Billroth, that, " Catarrhal con- 
junctivitis, which is so very common, may become diphtheritic." 

In a recent lecture delivered at the Sanitary Institute in 
London, Dr. Thorne Thorne, C.B., F.R.S., a medical officer of 



DIPHTHERIA— SEASON OF TEAR. 343 

the Local Government Board of England, expresses himself as 
fully convinced that diphtheria is disseminated through schools 
by failure to isolate or exclude pupils suffering with an ordinary 
or simple sore throat. He says : " Where sore throat ends and 
diphtheria begins, I cannot say ; but no child who is suffering 
from any form of sore throat should be allowed at school, nor 
even any one from the house in which that child resides." He 
gives many statistics to show that in outbreaks of diphtheria 
in towns and hamlets throughout England, school children are 
not only first affected, but as a rule those children who do not 
attend school are for the most part exempt ; notwithstanding 
a considerable epidemic may be prevailing. He further says : 
*' During the cold weather the people all get sore throat, and if 
you look into their throats, you will always find traces of ulcer- 
ation, due to past attacks of inflammation of the tonsils. The 
sore throat — an ordinary sore throat, so far — is passed from one 
to another (for all forms of sore throat are apparently infec- 
tious), and by and by — as I have observed over and over again 
— it gets worse and worse, until it culminates in an outbreak of 
diphtheria. The explanation that has occurred to me in respect 
of these circumstances, is a progressive increase in the infec- 
tiousness of the poison which produces diphtheria." 

Some years ago (1884), I I'^^d a paper before the Illinois 
Homeopathic Medical Association on ''The Cumulative Po- 
tency of the Diphtheritic Contagium." In this paper I instanced 
twenty-seven families in which there had been multiple cases 
of diphtheria, and in nearly all of which the second or subse- 
quent case was more severe than the first. I cited numerous 
instances in which the primary case was so mild as to be, in 
many of them, uncertain of diagnosis ; but the second case was 
severe, critical or fatal. My experience during the past ten 
years has only served to confirm this observation, and empha- 
sizes the importance of exercising the most rigid quarantine of 
every case of diphtheria or even of a sore throat, that is at all 
suspicious of being infectious in its nature. This question has 
a most practical bearing. Quite recently the press of this city 
strongly urged the establishment of a diphtheria hospital, 
where children affected with this disease could be taken and 
cared for, and where it was supposed they would be under 
better auspices than at their homes. Such an establishment 
would only add to the number of fatalities and do infinitely 
more harm than good. The more contagious diseases are 
aggregated, the greater the per cent, of mortalities, and with 
diphtheria this is preeminently true. Isolation of the first case 
and a quarantine more or less rigid of all forms of sore throat, 
is the only safe and scientific procedure. 



344 THE DISEASES OF CHILDREN. 

Contagium, — While tender age is a predisposing factor, and 
cold is frequently an exciting cause of diphtheria, many cases 
originate from a contagium emanating from some previous 
case. That the disease is distinctly and markedly contagious, 
no longer admits of doubt ; but we cannot agree with Jacobi, 
J. Lewis Smith and others, who assert that the contagium ex- 
tends but a few feet beyond the person infected. Some few 
years ago we attended the aunt of a two-year-old child, with a 
moderately severe attack of diphtheria. During the aunt's ill- 
ness the child crept out of its nursery on the lower floor, 
climbed the stairs, and peeped through the half-open door of 
the sick-room. It was during one of my professional visits, and 
as soon as the child's presence was noticed, it was hurried back 
to its own room. He was not in the hallway over half a min- 
ute, and did not enter the chamber. In spite of this, he took 
the disease after an incubative period of two days, and died ten 
days later. As to the nature of the poison which gives to 
diphtheria its contagious element, authorities differ greatly. 
To those who accept the germ theory of contagion, it would 
seem almost sacrilegious to even question the part which mi- 
crobes play in this disease. 

Ever since Buhl first discovered microbes in the diphtheritic 
deposit, and Hueter and Oertel simultaneously detected them 
in the subjacent mucous membrane and in the blood of those 
infected with the disease, no effort has been spared to identify 
the particular bacillus on which to fix the onus of responsibility. 
After numerous failures to find a bacillus in diphtheria that 
could not be found elsewhere, Klebs, in 1883, and Loffler, of 
Greifswald, in 1884, found one in the exudate and on the adja- 
cent mucous membrane, that so far seems to meet all the 
necessities of the case ; and the particular microbe which the 
germ theorists, or most of them, now consider to cause diph- 
theria, is known as the Klebs-Loffler bacillus. The causative 
relation of the germ to diphtheria is disputed even by some 
eminent bacteriologists ; while there are many, ourselves among 
the number, who are exceedingly skeptical about germs causing 
this, or any of the other contagious diseases. For the sake of 
those who are pursuing the study of the germ theory, and in- 
vestigating its merits, we give the following description of the 
bacillus diphtheria, as found in Pepper's ''American Text- 
Book of the Theory and Practice of Medicine," page 374. 

" The diphtheria bacillus is a little shorter than the tubercle 
bacillus, but is much broader and has thickened or clubbed 
extremities. It is sometimes curved, sometimes spindle- 
shaped. ... It is capable of deep staining, and then 
presents a segmented granular appearance. The bacilli often 



DIPH THERIA — C ON TA GI UM. 34 5 

occur in groups. On the outer surface of the false membrane 
several varieties of bacilli, including the Klebs-Loffler germ, 
are found. Immediately below, is a layer containing many 
cells and but little fibrin, and here, again, the bacilli in groups 
are apparent. Finally, in the deepest fibrin layer, which rests 
upon the mucous membrane, no Klebs-Loffler bacilli are 
present. (Welch, Abbott.) The bacillus diphtheria grows 
readily in a variety of culture media. It is killed at 58° C. in 
ten minutes. (Welch, Abbott.)" 

The writer from whom this description is taken. Dr. W. Gil- 
man Thompson, says that the bacillus, '' comes in contact with 
the faucial, or other mucous surface, or the abraded skin, and 
propagates there ; but it does not penetrate deeply into the 
mucous membrane, nor is it taken up by the blood-vessels or 
lypmhatics. The bacilli, therefore, do not invade the e7itire 
body, but remain at the site of the local lesion, imbedded in the 
pseudo-membrane.'' (The italics are ours.) 

The position taken by the early bacteriologists, that micro- 
organisms were directly implicated in the causation of disease, 
was soon found to be untenable. Hiller found microbes in the 
cadavers of those who had not died of septic disease, and many 
acute observers failed to find them except in close proximity 
to the original seat of infection, although there was, as in all 
severe cases of diphtheria, profound constitutional disturbances. 
Oertel propounded the theory that, while the inoculation was, 
by the action of the microbes, causing a local disease, this local 
disease extended through the organism and became general by 
means of the absorbents and lymphatics. Narsiloff, Eberth, 
Klebs, and others, by their experiments and exhaustive re- 
searches, endeavor to sustain this view, as do also Obermeir, 
Pasteur and Koch. On the other hand, Panum, Bergman, 
Schmeideberg and others have isolated poisons of marked 
septic power, which contained no bacteria whatsoever. Ram- 
itsch and many others have demonstrated that septic infection 
is not dependent on the existence of bacteria. It has been 
shown by Devein and others that an infinitely small amount 
of chemical poison, entirely free from bacteria, can kill quickly. 

It has been found by careful experiments by Hiller, Webber 
and Hemmer, that the injection of isolated bacteria in large 
numbers or colonies, into the sub-cutaneous cellular tissue of 
dogs and rabbits, produced a slight local swelling, but neither 
abscess nor fever. Hiller injected these into his own subcu- 
taneous cellular tissue, without producing any other effect 
than a slight edema. After these observations had been 
repeated and verified by numerous observers, the micro-or- 
ganisms were carefully classified into disease-producing and 



346 THE DISEASES OF CHILDREN, 

non-producing bacteria; for it was clearly demonstrated that 
many forms of bacteria were perfectly innocuous. 

It was further found that even the septic or disease-produc- 
ing bacteria were only the indirect producers of mischief. This 
indirect production of disease phenomena, was explained as 
due to the agency of "a specific product of the specific microbe, 
elaborated in the process of its growth or decay, the ' specific 
product' being in the nature of a peculiar poison possessing 
not only specific physiological action," but also having peculiar 
chemical properties and constitutions, which ally them more or 
less closely to certain well-known poisonous vegetable alkaloids. 
These chemical bodies have received the name of ptomaines or 
toxines. 

It is claimed that each infectious disease, diphtheria included, 
not only has its specific bacillus, but a specific ptomaine or 
toxine — the product thereof — which is the propagating con- 
tagium of the particular disease ; and it is further claimed that 
by inoculating a person with the special ptomaine of that dis- 
ease, such person secures immunity from the effects of subse- 
quent exposure. Many attempts have been made to guard 
cattle and smaller domestic animals from destruction by infec- 
tious or contagious diseases by such inoculation ; but such 
experiments have been thus far only partially successful, and 
the results are still in doubt. 

The theory is fascinating. In some instances the protection 
afforded by inoculation, notably those of Pasteur in the char- 
bon of sheep, is almost conclusive proof of the truth of the 
premises ; but no sooner does one experimenter report successes 
than others, equally trustworthy and skillful, report an equal 
number of signal failures. It may be true, as an enthusiastic 
writer of recent date says: ** The immunity acquired by surviv- 
ing a natural attack, or an artificial production of the disease, is 
secured by the action in the tissues of the specific microbe 
through its ptomaines ; and this action is probably due both to 
the restraining effect of the ptomaine itself upon the develop- 
ment of the specific bacterium, which generates it in a manner 
quite analogous to the effect of alcohol generated in the pro- 
cess of fermentation, in arresting at a certain stage the growth 
of the microbe which produces it, and to the establishment of 
a tolerance by the animal organism, for the poisonous alkaloid. 
When the properties of the various specific ptomaines shall 
become thoroughly known and well demonstrated, the success- 
ful and safe control of epidemic diseases will probably become 
a matter of certainty." * 



Keating, vol. i, page 190. 



DIPH THERIA — C ON TA GI UM. 347 

At the present writing this sounds Utopian, and at best it 
will be a long time before the human family will, by means of 
a series of inoculations, be rendered exempt from the conta- 
gious and infectious foes that hamper its usefulness and threaten 
its life. The time has not yet come when the germ theory, 
even as modified by its latest and most conservative exponents, 
can be accepted as conclusive. There are many facts which go 
to show that bacteria are merely accidental or incidental factors 
of secondary influence, when compared with other factors yet 
undiscovered and hence unknown. 

Some years ago Wood and Formad, under the direction of 
the United States Government, made some original investiga- 
tions, in order to ascertain the precise role played by bacteria 
in the causation of diphtheria. They made thirty-two experi- 
ments. Diphtheritic matter was injected subcutaneously and 
in the mucous membrane of the mouth. Only six animals 
■died, and of these one case alone presented exudations indicat- 
ing that death might have occurred from diphtheria. The in- 
ternal organs of the animals were tuberculous. The results of 
the experiments of Burden Sanderson, who produced tubercles 
in guinea pigs by inserting cotton threads in the skin, were 
further confirmed by Wood and Formad, in their experiments. 
In Wood's experiments, which consisted in introducing small 
masses of innocuous foreign substance under the skin, tubercu- 
losis was found in five after death. 

Dr. J. S. Mitchell, in his admirable article on diphtheria in 
Arndt's "System of Medicine," says in this connection: 

" Experiments have demonstrated that ammonia, cantharides, 
and other chemicals, may induce the growth of a pseudo-mem- 
brane, when introduced into the system. It has been shown 
that bryonia has this effect. M. Currie {British Journal of 
Homeopathy, vol. 19, p. 455), made the following experiment: 
He gave a rabbit increasing doses daily of the tincture of bry- 
onia, until he came to 250 drops, when he developed a firm 
pseudo-membrane extending from the larynx to the bronchioles 
■of the third degree. It would, therefore, seem that diphtheritic 
matter, artificially introduced within the body, is not so likely 
to produce the characteristic lesion of diphtheria as some other 
substances. Experiments were performed with organic matter 
to see if products of disease other than diphtheritic exudations 
would give the pseudo-membrane. The material was pus in 
four instances. Two of these gave false membrane, so this 
result was better than where diphtheritic matter was used. 
The conclusion of Wood and Formad is : The contagious ma- 
terial of diphtheria is really of the nature of a septic poison, 
which is locally very irritating to the mucous membrane, so 



348 THE DISEASES OF CHILDREN, 

that, when brought in contact with that of the mouth and 
nose, it produces an intense inflammation without absorption 
by a local process. While absorption is not necessary for the 
production of the angina, it is very probable that the poison 
may act locally after absorption by being carried in the blood to 
the mucous membrane. Further, under this theory it is pos- 
sible that the poison of diphtheria may cause an angina which 
will remain a purely local disorder, no absorption occurring ; 
or a simple local tracheitis, produced by an exposure to cold or 
some non-specific cause, may produce the septic material, when 
absorption will cause blood-poisoning, the case ending in 
adynamic diphtheria. 

** Some such explanation as this here offered seems to recon- 
cile the antagonistic opinions concerning the value of local 
treatment in diphtheria, because it is plain that the value of 
such treatment must largely depend on whether the angina has, 
or has not, been produced by absorption. At present it seems 
altogether improbable that bacteria have any direct action in 
diphtheria — that is, that they enter the system as bacteria, and 
develop as such in the system, and cause the symptoms. It is, 
however, probable that they may act upon the exudation of 
the trachea, as the yeast-plant acts upon sugar, causing the pro- 
duction of a septic poison which differs from that of ordinary 
putrefaction, and bears such relations to the system as to cause 
the systemic symptoms of diphtheria when absorbed. Now, 
these bacteria may always be in the air, but not in sufficient 
quantities to cause tracheitis, but enough, when lodged in the 
membrane, to set up the peculiar fermentation ; whilst during 
an epidemic they may be sufficiently numerous to excite 
inflammation in a previously healthy throat. The investiga- 
tions and experiments of Wood and Formad are the most 
complete and conclusive on this subject which we have yet 
had, and they confirm the view, long held by some, that the 
bacteria may fall in showers upon the unprepared mucous 
membrane, and not induce diphtheria, and that the real etio- 
logical factor, or factors, which render it susceptible to their 
action, are yet unknown." 

To sum up the net results of the tireless investigations and 
experiments that have been carried on in this connection 
during the past twenty-five years, both in this country and in 
Europe, by the ablest scientists in the world, it can only be 
said that the cause, the essential factor in the production of 
diphtheria — the one-element without which the disease is not — 
is di poison] a fact that was known a thousand years before the 
Christian era. Whence it originates, whether from within or 
without : whether it be a product of disturbed metabolism — a 



DIPH T HER I A — \ V TALITT OF P OIS O X. 349 

sudden vitiation of normal secretions; or whether it be from 
the inhibition of poisonous emanations from polluted soil, we 
are just as much in the dark as was Hippocrates or Galen. 
It is helpful, nevertheless, to call it a "poison," and to treat it 
as such. 

We are not called upon to regard a drug as valuable or val- 
ueless, according to its real or supposed power to kill germs. 
We are left free to revert back to such empirical treatment as 
clinical experience has indorsed, and to pursue our investiga- 
tions and researches in the field of therapeutics, solely intent on 
finding that which will reach and wipe out the symptoms of 
disease, regardless of germs or their hypothetical ptomaines. 

Vitality of the Poison. — However we may regard the nature 
of the contagious principle, or element, its power for mischief 
is of very long duration. Like the infection of scarlatina, which 
it strongly resembles in many other respects, it may retain its 
poisonous properties for months or even years. In 1888, we 
saw a case of diphtheria in consultation with Dr. C. E. Williams, 
of this city. It was a malignant case, and was practically 
hopeless at the time we saw it. A year or more afterward we 
were called to see an infant of an old client who had been long 
absent from the city, and who, on his return, had rented this 
same house. After the death of the child before alluded to, 
the house had been thoroughly disinfected — as was supposed — 
the inner walls had been newly papered, the woodwork re- 
painted and the floors throughout newly carpeted. My friends 
were ignorant that the house had previously harbored an infec- 
tious disease. Their occupancy had scarcely been a full week, 
when the infant, a year old, was taken ill with diphtheria, and 
died some nine days later. The only surviving child, a girl of 
ten years, was sent to a neighbor's as soon as the nature of the 
disease was recognized ; but she developed malignant diph- 
theria the following morning, and she also died after a brief 
illness. 

In culture experiments, the poison has been known to retain 
its virulence for sixteen months. According to Sevestre, in a 
Normandy village, twenty-three years after an epidemic of 
diphtheria, some of the bodies of those who died of the disease 
were exhumed and an epidemic at once broke out, first among 
those who opened the graves, and extended to others. Un- 
doubtedly the diphtheric poison has great tenacity of life and 
too great precautions cannot be taken to prevent its further 
spread. 

Varieties. — Between the mildest and the malignant form of 
diphtheria, as it is clinically encountered, there is a vast differ- 
ence. In concluding a report of a recent investigation of this 



350 THE DISEASES OF CHILDREN. 

question, Abbott says: "From these observations we feel jus- 
tified in agreeing with the opinion that has been advanced by 
other observers, particularly Hoffmann and Rowe and Yersin, 
that under varying conditions the virulence of the true diph- 
theria bacillus may be observed to fluctuate in the degree of 
its intensity — at one time possessing the property in a high 
degree, at another, presenting a decided attenuation, and not 
unfrequently a complete absence of pathogenic power." If, in 
the above extract, we substitute for " bacillus," contagium, or 
"■ poison," we shall understand how age, susceptibility, consti- 
tution, environments, attenuation or concentration of virus, may 
so modify the disease in a given subject as to render it scarcely 
distinguishable from some milder affection, or render it so ma- 
lignant as to be fatal within a few hours. 

By some authorities the disease is classified according to the 
particular region principally affected. Thus, these authorities 
make a distinct class of pharyngeal, laryngeal, and naso-pharyn- 
geal diphtheria. But there is little practical benefit to be 
derived from this multiplication of terms. Whether the disease 
be mild or malignant, it is liable to invade primarily or seconda- 
rily any of the mucous orifices ; and it may even invade the 
system through an abrasion of the skin or an open wound, 
wherever situated. The most common seat of the local lesion, 
however, is on the tonsils, from whence it is prone to extend 
into the pharynx, onto the uvula, and the palate, and in a cer- 
tain proportion of cases it begins in or extends to the larynx, 
when its dangers are always greatly increased. 

Immunity. — There is much difference of opinion among ob- 
servers as to whether one attack of diphtheria does or does not 
confer immunity from future danger. The majority of accessi- 
ble authors is decidedly in favor of the non-protection side 
of the question. Our own opinion is that in this case, the 
majority is wrong. In nearly thirty years of continuous 
general practice, we have never seen diphtheria repeated in 
the same subject. Having had the disease ourselves in a mild 
form some seventeen years ago, we have since then attended 
scores of cases, of all degrees of severity, without a second 
infection. 

In exceptional cases both scarlatina and variola are repeated 
in the same subject, and the same is true of rubeola. The ex- 
ceptions, however, only prove the rule. We do not scruple to 
assure our patients, who have once been attacked by a distinct 
diphtheria, that they need have no fear of a recurrence. 

While diphtheria is indubitably contagious, its infective prop- 
erties are considerably less than those of scarlet fever. It is 
not, as a rule, propagated by means of fomites, as is the latter 



DIPHTHERIA— PROGNOSIS. 351 

affection. We have never known a case of diphtheria resulting 
from a physician carrying the infection in his clothing, although 
it frequently happens that he is compelled to go from an in- 
fected house to one where there are unprotected children. 

There is no adequate explanation for this, except that the 
contagium is quickly dissipated in the outer air or speedily per- 
ishes except in confined areas. Dr. Mitchell's theory of account- 
ing for this fact is at least ingenious. He says : *'A reasonable 
theory would seem to be that the physician combines in his 
person so many of the specific causes of different diseases as 
not to allow any one to be signally operative." 

hiaibation, — So many circumstances interfere with observa- 
tions on this score, and so difficult is it usually to trace the dis- 
ease to its distinct source, that no certain period of incubation 
can be given. Doubtless it differs in different cases. In a sus- 
ceptible subject it may be but a few hours, while in one less 
susceptible it may be many days. From our own and the ob- 
servation of others, the period may be said to be from two to 
seven days — in some cases longer. We have several times 
noticed the invasion to be two days after known exposure, and 
in one case it was four days. 

Duration. — Diphtheria is a disease of indefinite duration. 
The average case lasts from ten days to a fortnight. Very 
mild cases may terminate in a week, while those which are more 
severe, may last three or four weeks. Cases are on record 
where complete recovery did not take place until after several 
months. The sequelae, such as paralysis and albuminuria, may 
last indefinitely, although as a rule the duration is not over a 
few weeks. 

Prognosis. — This should always be guarded. The disease is 
full of pitfalls and disappointments. The prognosis varies in 
different epidemics. So long as the heart's action is strong and 
the digestive powers remain good, there is every ground for 
hope. Under such circumstances, and in the absence of exten- 
sion of the membrane to the nose or larynx, the prognosis is 
favorable. If the patient is seen early and is of good constitu- 
tion, proper treatment ought to afford a good chance for recov- 
ery. When diphtheria complicates a case of measles or scarlatina, 
which has already sapped the vitality of the child, the prognosis 
is less favorable. The younger the child, the more apt the 
disease is to prove fatal. The amount of pseudo-membrane is 
not usually to be depended upon as a criterion for estimating 
the gravity of the attack. There may be but a few traces of it 
in the fauces, and yet a great amount of systemic poisoning. 
On the other hand, the fauces maj^ be thickly covered with a 
dense membrane and yet recovery take place. 



352 THE DISEASES OF CHILDREN. 

Mortality. — It is very difficult to correctly estimate the mor- 
tality from this disease. Many physicians in good professional 
standing are densely ignorant of its proper diagnosis. They 
will tell you that they have treated fifty or a hundred 
cases of diphtheria without losing a single case ; while all au- 
thorities place the mortality at from 40 to 75 per cent. With 
900 cases recently treated in Strasburg, the mortality was 46.7 
per cent. In New York City, according to Thompsen, it aver- 
ages above 47 per cent, and may reach 55 per cent. Over 50 
per cent, of deaths from diphtheria occur in children under five 
years of age, and about 75 per cent, occur among those under 
ten years of age. 

These figures are taken from general current statistics. We 
have no exact data as to the relative mortality under homeo- 
pathic treatment ; and it would be unfair to assume superior 
results without supporting data. 

The employment, however, of such heroic measures, both 
topically and internally, as has characterized old-school methods, 
based upon the belief that the most powerful germicides were 
alone equal to combat the hordes of micro-organisms found in 
and about the pseudo-membranes, could not do otherwise than 
render mild cases severe ones, and take from many the chance 
of recovery which would have been theirs had nature been left 
alone to exercise her restorative powers. 

Are True Croup and Diphtheria Identical? — Many of the 
older writers, and indeed some recent and most reputable au- 
thorities, such as Bretonneau, Morell McKenzie, and Sir Wil- 
liam Jenner, in Europe, and Jacobi and Loomis in this country, 
have expressed themselves as believing in the essential identity 
of diphtheria and cynanche trachealis, or true croup. Others, 
and among them we must emphatically place ourselves, observe 
so many vital points of difference between the two diseases 
that we are constrained to consider them as distinct and sepa- 
rate affections. Diphtheria is a general or constitutional 
disease of markedly asthenic character, while true or membra- 
nous croup, is a local affection of sthenic type. There is always 
a more or less pungent odor about diphtheria which is absent 
in croup. Diphtheria, starting in the larynx, seldom or never 
progresses upward. True croup often does. The importance 
of the question is most certainly one which can hardly be over- 
estimated, for it has a bearing not only on the therapeutic 
management, but upon the prognosis and the prophylaxis as 
well. In order to assist the reader in differentiating the one 
from the other, and the more clearly to contrast their salient 
features, we place their more prominent symptoms side by side 
in the following table of comparison. 



DIPHTHERIA— PA THOL OG T. 



353 



Distinctive Diagnosis Between Membra7ioiis and Diphtheritic 
Croup. — The Pacific Medical and Surgical Journal presents the 
following — as abbreviated, with emendations, from Dr. Hugo 
Engel's statement in the Philadelphia Medical and Surgical 
Reporter: 



Membranous Croup. 

Cause, exposure to cold. 

Period of incubation, none. 

A local history at beginning. 

Constitutional symptoms secondary. 

Begins in larynx. 

May extend upwards. 

Affects children only. 

Begins suddenly in the night. 

Loss of strength near the end. 

Death from apnea. 

No complications. 

Albuminuria only towards the last. 

Glands not enlarged. 

Never contagious. 

No sequelse. 

Convalescence rapid. 

Membrane soluble in potash solution. 

Hardened by sulphuric acid. 



Laryngeal Diphtheria. 

Cause, specific poisoning. 

One to five days or more. 

Constitutional. 

Primary. 

In pharynx. 

Extends downwards. 

Adults also. 

Prodromes for some days. 

From the beginning. 

Often from ataxia. 

Nose and heart often implicated. 

From the outset. 

Always enlarged. 

Decidedly contagious. 

Paralysis often. 

Slow and tedious. 

Soluble in sulphuric acid. 

Hardened by potash solution. 



Pathology. — It has always been a mooted point as to the 
relation which the pseudo-membrane bears to the constitutional 
disorder. By many it is claimed that in the beginning diph- 
theria is always a local disease, and that if seen in its earliest 
stages, the poison may be neutralized by judicious treatment, 
and constitutional infection in this way prevented. This was 
the opinion of the late Prof. W. F. Knoll, who strongly advo- 
cated the topical use of strong carbolic acid. Except in rare 
instances, the first perceptible lesion is in the fauces, and on the 
tonsils, and symptoms of general infection are usually not 
observed until some hours — or days in some cases — after the 
pseudo-membrane has shown itself. But fatal cases of diph- 
theria have been recorded in which there was no deposit, either 
on the tonsils or anywhere in the throat. Thus, M. Trousseau 
observed cases of diphtheria in a village in the neighborhood 
of Orleans, where diphtheria prevailed, presenting in some 
cases its ordinary features ; manifesting itself in others by 
deposits of false membrane on the vulva, or the mammae, on 
blistered surfaces or on ulcers, and *' proving fatal in some cases 
without the throat being at all involved in the disease." The 
great depression of vital powers, which is so characteristic of 
the disease, sometimes manifests itself even before the throat 
symptoms, and in malignant cases death has been known to 
D. C— 23 



354 THE DISEASES OF CHILDREN. 

take place before the real nature of the affection was recognized 
— the cause of death being only revealed post-mortem. 

The albuminuria which usually accompanies its severer forms, 
and may even be present in its milder aspects, is sometimes 
seen among the earliest symptoms. Again, we sometimes 
encounter, even quite early in the disease, disordered innerva- 
tion of the vital centers, showing a close relationship to those 
affections attended with profound blood-poisoning of which the 
local manifestations, wherever situated, give but a vague and 
uncertain indication. 

Dr. J. Lewis Smith cites the case of a girl of five years, having 
malignant diphtheria, to whom he was called in consultation, 
and who was carefully examined by the attending physician, 
and, although he closely inspected the fauces, there was no 
appearance which indicated the nature of the malady till the 
subsequent day. 

In several similar cases which we have observed, there has 
been for a day, or a portion of a day, prior to visible exudation, 
complaint of soreness of the throat, or difificulty of swallowing; 
but the pain and tenderness seemed to be in the deeper tissues 
of the neck. The treatment of the local inflammation by the 
most reliable and efificient antiseptics and disinfectants, com- 
menced at the earliest possible moment, and repeated at short 
intervals, does not prevent the occurrence of indubitable symp- 
toms of blood-poisoning in cases of severe type. 

Just why the pseudo-membrane is so prone to show itself 
first on the tonsils, has never been satisfactorily explained. 
Extirpation of the tonsils does not prevent infection. In its 
physical properties, the exudation is identical with the fibrin 
of the blood. It has an alkaline reaction, swells, and becomes 
transparent in strong acetic acid, and is disintegrated or dis- 
solved by caustic alkalies. According to Weigert, the fibrin is 
derived mainly from inflammatory exudation, which transudes 
from the capillary walls, and which is coagulated by ferment 
derived from disintegrated leucocytes. The mucous membrane 
beneath the exudate is more or less necrotic, and the sub- 
mucous layer is also necrotic in bad cases. As the inflamma- 
tion subsides, the necrosed portion of mucous membrane 
sloughs off, together with the pseudo-membrane, and the 
epithelial surface is restored by outgrowth from neighboring 
cells. 

Several successive membranes may form at the same site, 
and this is especially the case when they are forcibly stripped 
off. When left to take its natural course, the exfoliation occu- 
pies several days. While the pseudo-membrane is forming, its 
thin edges shade into the surrounding area of inflammation ; 



DIPHTHERIA— PATHOLOGT. 355 

but after a time, if repair is about to begin, the patches thicken 
and wrinkle about the edges, which become raised above the 
surrounding unaffected mucous membrane. Sometimes, owing 
to effusion of serum or ulceration beneath, the pseudo-mem- 
brane sloughs off in one entire mass : but more often it melts 
down imperceptibly, or comes away in fragments. Abrasions 
of the mucous membrane aid the spread of the virus, by afford- 
ing new fields for infection ; hence the danger of forcibly strip- 
ping off the false membrane, and exposing raw, bleeding 
surfaces. 

The lymphatic glands of the neck are apt to be the seat of 
hyperplasia. This is especially true if the nares are involved. 
Sometimes the cellular tissue surrounding the gland becomes 
infiltrated and greatly swollen. In either event, as a rule, the 
swelling subsides without suppuration. In malignant cases the 
odor from necrotic tissues is pronounced. There may be deep 
sloughing or even gangrene at the site of local inflammation, 
and hemorrhages are not uncommon from various portions of 
the affected mucous membrane. 

The spleen, and the liver also, may become hyperemic. The 
ventricles of the heart are often dilated ; but " heart failure," 
is due usually to poisoning of the pneumogastric center. Peri- 
carditis is occasionally observed, and in a few instances a 
granular, or fatty degeneration of the heart walls has been 
observed. As a result, the heart walls become softer in con- 
sistence, and extravasations of blood take place in them. 

The kidneys are often the seat of organic changes quite early 
in the progress of the disease. There is more or less granu- 
lar deposit in the renal cells, and the cells themselves are often 
detached so as to block up the tubes. They are mixed with 
hyaline casts. 

Various pathological changes have been noticed in the nerv- 
ous system, particularly by Charcot and Vulpian, who were 
the first to record their investigations in this direction. Oertel 
in 1871 found many extravasations in the substance of the 
brain, spinal cord, and spinal nerves, in a case where death had 
occurred from diphtheritic paralysis with general atrophy of 
muscle. Dejerine, in five cases of death in children from diph- 
theritic paralysis, found in each instance changes strictly limited 
to the nerves supplying the paralyzed parts. These changes 
consisted in a degeneration of the anterior roots similar to that 
which takes place in the distal end of a nerve after section. 
He attributed the degeneration to changes in the gray matter 
of the anterior cornua. Whether the nerve lesion accompany- 
ing these paralyses is central or peripheral, is not definitely set- 
tled. Vulpian, Abercrombie, Dr. Percy Kidd and others, hold 



356 THE DISEASES OF CHILDREN. 

to the former opinion, while Drs. Hughlings, Jackson, Woakes, 
and others equally eminent consider that the paralysis is due 
to a high degree of dilatation of the nerve vessels, and conse- 
quent exudation in the nerve sheaths, causing compression of 
the motor fibers. 

In a certain proportion of cases, the skin shows an erythe- 
matous eruption strikingly resembling that of scarlatina ; but it 
is not so generally diffused, and does not extend over the sur- 
face of the body in the regular way in which it does in the 
simple form of this latter disease. It is not common for the 
eruption, however extensive, to be followed by desquamation. 

In nasal diphtheria, it is not uncommon for pus to form 
underneath the pseudo-membrane formed within the nares and 
perforate the nasal duct, or even to burrow through the over- 
lying cuticle. 

Symptoms. — In diphtheria the prodromal symptoms are usu- 
ally slight and ill-defined, and seldom continue longer than 
twenty-four or thirty-six hours. They may be wanting alto- 
gether. When present they consist of lassitude, headache, 
muscular pains, fever, and pain on swallowing. In severe 
cases, there may be chilliness, even rigors, nausea and vomit- 
ing, and in infants the disease maybe inaugurated with convul- 
sions. Except in very severe cases, the fever does not run 
high. The temperature is rarely above ioi° or 102°. Even 
in mild cases there is commonly a nasal quality to the voice, 
which may become more marked as the disease progresses. 
An examination of the throat shows the fauces to be red and 
somewhat swollen, but more so on one side than the other. 
The uvula is usually increased in size and of a bright-red color. 
On one and sometimes on both tonsils, there will be observed 
a gray or yellowish-white opaque patch, which seems to be plast- 
ered onto the anterior surface. This patch may be round or oval 
in outline, or perhaps more commonly in the very beginning, 
appear in streaks, which afterward coalesce into an opaque and 
tough pseudo-membrane, which seems set in the mucous mem- 
brane like a watch-crystal in its case. 

In the first few hours of the disease, the exudation may be 
filmy and transparent in character, resembling that often seen 
in simple angina ; but very soon it becomes opaque, tough and 
leathery, and dips down into the mucous membrane so that it 
cannot be detached except by the use of considerable force. 
In case force is used and a portion of the exudate is torn loose, 
a raw and ulcerated surface is found beneath, which bleeds, 
and in a few hours the pseudo-membrane is reformed over its 
original site and as firm and adherent as before. The tenacity 
with which this false membrane clings to the deep tissues is 



DIPHTHERIA— SYMPTOMS. 357 

one of the pathognomonic features of the disease. The exudate 
which is seen in simple or folhcular tonsilitis, can be wiped 
off with little effort, while that of diphtheria must be torn ofT, 
if it be artificially removed. 

As the disease progresses, the exudation spreads until it 
covers or may cover both tonsils, the pharynx, the uvula, the 
pillars of the pharynx, and even portions of the hard palate. 
Only in very mild cases is the false membrane confined to one 
tonsil or one side of the throat. The cervical glands are early 
involved in most cases, and become swollen and tender. The 
glandular swelling is bilateral and symmetrical. The constitu- 
tional symptoms are by this time well marked. The pulse is 
rapid, 120 or 140, and weak. The first sound of the heart is 
perceptibly weakened. There is a sense of extreme prostration. 
The patient feels ill and looks pallid. In some cases there is 
but little if any pain in deglutition. The nerves of the throat 
are anesthetic. When pain in swallowing is felt, it is usually 
more on one side than the other, and generally on the side 
where there is the least exudation. In mild cases, the exuda- 
tion loses its tough, leathery character after from two to four 
days and becomes darker in appearance ; it loosens about the 
edges, which curl up like parchment. It becomes thinner and 
softer, and either melts away perceptibly, day by day, or is 
hawked up in shreds or pieces. If the membrane reaches to 
any great extent the vault of the pharynx, it invades the pos- 
terior nares, and comes forward to fill the nasal cavities. When 
this occurs, the fact is evidenced by a thin, acrid discharge 
from the nose, of muco-purulent character, which may excori- 
ate the septum, the alae and upper lip. This discharge is very 
offensive in odor and may be mixed with blood. 

The discharge blocks up the nasal passages and renders 
mouth-breathing necessary. Young infants cannot suckle and 
must be fed with a spoon. Nearly all cases of nasal diphtheria 
are attended by swelling of the glands at the angle of the jaw, 
owing to their close connection with the lymphatic vessels of 
the Schneiderian membrane. Indeed, this swelling of the par- 
otid and submaxillary glands may be the first signal that the 
disease has invaded the nasal passages. Sometimes the connec- 
tive tissue surrounding the glands becomes infiltrated, so that 
the entire neck is greatly swollen. Epistaxis is common and 
may be uncontrollable, owing to the non-coagulability of the 
blood. 

In cases which terminate favorably, the false membrane sep- 
arates and is not renewed. The swelling subsides, the appetite 
returns, the pulse becomes stronger, and unless some complica- 
tion ensues, a slow convalescence begins. Often, however, the 



358 THE DISEASES OF CHILDREN. 

patient succumbs at the end of a week, either from exhaustion, 
or extension of the false membrane into the larynx, or from 
some other complication to be presently described. The mind 
is usually clear to the very end, although, in rare cases, death 
may be preceded by delirium or coma. Apathy is one of the 
singular characteristic features of diphtheria. The patient does 
not complain of pain, usually — only of being tired. Relapses are 
frequent, either from reinfection of the system, or from other 
causes, and in such cases chilliness is complained of ; the 
temperature, which has been normal, or but little above normal, 
suddenly rises to 103° or 104°, sinking again in irregular varia- 
tions ; the pulse is rapid, small and feeble ; the eyes are 
sunken and dull ; the strength rapidly diminishes; the prostra- 
tion is extreme ; delirium comes on, and the child quickly dies. 
The amount of fever in diphtheria varies greatly. Even in 
bad cases it need not be high. Whether high or low, it affords 
no criterion by which to estimate the gravity of the attack, un- 
less it be abnormally so. Albuminuria occurs in about two- 
thirds of the cases, but this does not necessarily imply gravity 
in the prognosis. Its amount is greater usually in proportion 
to the amount of the exudate. The early appearance of albu- 
min in the urine — that is, within the first forty-eight hours — 
only occurs in severe cases. In cases of mild or moderate 
severity, it does not appear before the third or fourth day. It 
may be delayed as late as the ninth or tenth day. The urine is of 
high specific gravity, and contains an excess of urea, with hyaline 
and granular casts. The kidneys are in a state of mild paren- 
chymatous nephritis; but this passes off as convalescence be- 
comes established, and rarely leaves ill consequences behind. 
It is rare for uremic symptoms or dropsy to occur. 

Laryngeal Diphtheria. — The diphtheritic poison, instead of 
finding for itself a nidus in the pharynx, may in exceptional 
cases develop in the larynx, the trachea, or, as in a case we saw 
some years ago, in the upper bronchi. 

When diphtheria invades the larynx primarily, there are 
no special symptoms by which we can differentiate it from true 
membranous croup, except in those rare cases in which, by an 
extension upwards, it involves the pharynx subsequently, and 
there manifests its distinctive peculiarities. There is no odor 
to the breath ; the dyspnea is not different or greater ; and 
indeed it is practically impossible to distinguish one from the 
other, except in cases where there is a distinct history of 
diphtheritic exposure. It is this fact that has led so many 
high authorities to regard the two diseases as identical. 

In the majority of cases of laryngeal diphtheria, however, 
the larynx is not involved primarily. It is due to an extension 



DIP}! T HER r A— LA R 1 WGEA L. 359 

of the inflammation downward from the pharynx. This ex- 
tension to the air-passages often takes place suddenly and unex- 
pectedly. The preceding symptoms may have been slight and 
attracted but little attention. There may have been but a 
modicum of inflammation or exudation in the pharynx. The 
whole array of symptoms may have been of the mildest type, 
when suddenly the breathing becomes stridulous, or a croupy 
cough sounds the first signal of danger. 

The symptoms which characterize membranous croup then 
develop themselves with startling rapidity. Hoarseness follows, 
which may be quickly succeeded by aphonia. The breathing 
becomes quick and shallow, or noisy and stertorous. The counte- 
nance becomes cyanotic and anxious ; the patient sits up or 
tosses in bed, gasping for breath, the alae nasi working vigor- 
ously with all the accessory respiratory muscles called into 
action. The breathing is superficial, rapid and irregular. Each 
inspiration is prolonged and high-pitched ; the expirations 
shorter and harsh. The cough is hoarse or whispering. Owing 
to obstruction to the entrance of air, the supra-claricular spaces 
and the lower intercostal spaces are sunken by atmospheric 
pressure during inspiration. 

The patient may cough up pieces of membrane and thus 
secure a temporary respite from impending death ; but the 
dyspnea soon returns from the re-formation of new membrane. 
Even where the membrane is not coughed up, the dyspnea is 
paroxysmal. It lasts from a few minutes to a quarter of an 
hour, or longer. During the periods of respite the child's ter- 
ror disappears ; his respiration becomes less noisy and stridu- 
lous ; his respiratory movements are less laborious, and for a 
time he is in a state of comparative ease. Still the breathing 
does not altogether resume its natural character. It is rapid 
and audible. The alae nasi continue to work violently and 
some lividity still lingers in the countenance. It is rare that 
enough membrane is coughed up to afford more than partial 
relief. The dyspnea recurs at short intervals, and at each re- 
currence is more severe than before, so that the child is speed- 
ily exhausted in strength or passes into a state of semi-asphyx- 
iation. The forehead becomes clammy and the extremities 
cold. The lips become purple and the face livid. Usually, if 
not relieved by tracheotomy or intubation, the child does not 
survive more than twenty-four or thirty-six hours from the 
time when the larynx was first involved. Sometimes, however, 
if the false membrane is of limited extent, or is confined to the 
lower portion of the larynx, recovery may take place. In 
other cases when the child's strength is good and time is 
given for the action of suitable remedies, a favorable change 



360 THE DISEASES OF CHILDREN. 

may take place and the stenosis be relieved by coughing up a 
considerable portion of membrane, which is not thereafter re- 
newed. An extension of diphtheria into the nares is always 
attended with danger, and into the larynx with almost neces- 
sarily fatal results, unless surgical measures are promptly 
resorted to, in which case life may be at least prolonged, 
and in some cases undoubtedly saved. Laryngeal diphtheria, 
however, must be regarded as the most fatal of all infantile 
maladies. 

Complications and Sequelce. — Diphtheria is more apt to com- 
plicate other diseases, such as measles and scarlatina, than to 
itself be complicated by them. The extension of the false 
membrane into the larynx or the trachea, in the course of an 
attack of diphtheria, is the most serious of these complications. 
The presence of albumin in the urine is by all means the most 
common, occurring in probably two-thirds of the cases, regard- 
less of gravity. But its presence or absence is not to be seri- 
ously regarded. In rare cases there is local edema, and possibly 
anasarca ; but the nephritis which is set up by the diphtheria 
is usually of temporary duration and trifling in results. 

Among the sequelae, paralysis of local muscles is exceedingly 
common, and is liable to follow in the wake of the disease, how- 
ever mild the attack may have been. This paralysis may be 
partial, amounting to slight impairment of function, or it may 
be complete. It may be, and commonly is, limited to a single 
group of muscles, or it may involve in succession almost the 
whole voluntary muscular system. The advent of these paraly- 
ses is always insidious, and, as a rule, is noticeable during the 
second or third week of convalescence. Trousseau mentions a 
case in which the paralysis manifested itself some days before 
the complete disappearance of thfe false membrane. McKen- 
zie states that the paralysis may develop as late as the sixth 
week of convalescence. In all cases their advance is gradual, 
and they may continue to extend for several weeks after their 
first appearance. The muscles most frequently affected are 
those of the soft palate, the eyes, and those of the extremities. 
When the former are affected, a nasal tone is given to the voice, 
and there is difficulty in phonation, owing to the impossibility 
of closing the naso-pharyngeal passage. A patient thus will 
pronounce rub, rum, head, heizt, and Qgg, enk. In connection 
with indistinct articulation, there is frequently strabismus, di- 
latation of pupils, and imperfect vision. The taste is often more or 
less blunted, and sometimes the power of expectoration is lost. 
In^some cases there is impairment of the pneumogastric, and a 
nervous cough is developed, or the respiration becomes sighing, 
as if from exhaustion. A year ago we took care of a pair of 



DIPHTHERIA— TREATMENT. 361 

twins, five years old, simultaneously sick with mild diphtheria. 
During convalescene the little boy began twitching his eyelids, 
and this involuntary muscular action subsequently extended to 
nearly all parts of the body. After a month or six weeks he 
made a good recovery, and has not been troubled since. 
Some six months after recovery from the diphtheria, his twin 
sister began sighing at frequent but irregular intervals, and this 
increased to such an extent that she was brought back to me 
for treatment, and she also made a good recovery in the course 
of a few weeks. 

Paralysis of the extremities is occasionally met with, but is 
seldom complete, being generally of an ataxic character, ren- 
dering the movements uncertain, tottering or hesitating. In 
such cases there is numbness and tingling in the affected mem- 
bers. Cardiac syncope is not uncommon, even in cases that 
show no other sign or evidence of neurotic complication. It is 
not without danger, as numerous cases are recorded of sudden 
death after convalescence was supposed to be well established. 
Violent exercise should be strictly prohibited to those who are 
recovering from diphtheria, until a full restoration of strength 
has been secured. 

There is some tendency of the diphtheritic membrane to 
extend down the esophagus, and invade the stomach. It is in 
such cases that we have such repugnance to and intolerance of 
food. Vomiting is frequent, although not always present. 
Epigastric and precordial pain is usually complained of, and is 
sometimes a marked and distressing symptom. 

Treatment. — The successful treatment of diphtheria must 
be based upon the law of similia. Any other treatment must 
be empirical, uncertain and unsafe. As we have seen in the 
preceding pages, the disease in its malignant form is character- 
ized by profound depression of the vital forces, and a demoral- 
ization of the blood arises in consequence. 

This is sometimes manifested prior to the visible formation 
of any distinctive false membrane, either in the throat or else- 
where. In such cases any attempt to abort or control the dis- 
ease by local applications would be manifestly absurd. Even 
where, as is the case usually, the formation of false membrane 
precedes the constitutional symptoms, the employment of 
escharotics and germicides, with the hope of destroying the 
poison at the seat of infection, has proven a dismal failure in 
the vast majority of cases. In saying this we do not mean to 
decry the use of local measures altogether, for we firmly be- 
lieve in them — some of them — as will be seen presently. What 
we do mean is, that the use of strong carbolic acid, nitrate of 
silver, or the bichloride of mercury, as a destroyer of germs, 



362 THE DISEASES OF CHILDREN. 

and therefore a remedy for this disease, is not sanctioned by 
common sense, by scientific study, nor by clinical experience. 

In the milder forms of the disease, we are confident that 
such measures as we have just mentioned are not only useless 
but most pernicious. There are antiseptics of the first class, 
which are entirely free from objection, that could not do harm 
if applied properly to a throat in perfect health, and which 
nevertheless are of accredited germicidal power, and of proven 
efficacy. One of the best of these and one that has stood the 
longest clinical test is permanganate of potash. It has no 
equal as a deodorizer. It can be used as a gargle, if the patient 
is old enough, or it may be used as a spray by any form of 
atomizer. One of the best methods of using this or any of 
the other antiseptics is by means of an Alpha syringe with an 
acorn tip. This throws a continuous stream, and it can be used 
as a nasal douche, or it can be made to reach the post-nasal 
and pharyngeal surfaces at will. While the permanganate is 
quite harmless if taken in tangible doses, its effects are secured 
by using it in the strength of one or two grains to the ounce 
of water. 

Eucalyptol is a remedy highly spoken of by Dr. E. M. Hale. 
The liquor calcis chlor. has many advocates, and is highly 
praised by Neidhard ; but its efficiency seems to be limited to 
mild cases, in which there is but little false membrane. 

But the local remedy par excellence^ is peroxide of hydrogen. 
It has many advantages over any other, and can be used by 
spray, lavage, gargling or douching. It can be swallowed, even 
by infants, semi-diluted, with impunity. In taste it is scarcely 
less disagreeable than water. It has no toxic dose. Pus can- 
not exist in its presence. It is deoderant and germicidal. It 
loosens the false membrane from its attachments by destroy- 
ing the purulent matter underneath and around it, and thus 
hastens its elimination. It does more than this. When brought 
into contact with the mucous surfaces, it is absorbed to a greater 
or less extent, and thus assists in the essential process of blood 
oxydation and purification. In other words, its antiseptic 
properties extend beyond local contact, and it helps, besides, 
the oxygenation of the blood, thus acting as a powerful volatile 
stimulant. 

In order to secure the best results from the use of the per- 
oxide, certain precautions must be taken. So far as our pres- 
ent knowledge goes, that prepared by Charles Marchand is the 
best. Even this preparation is very unstable and rapidly de- 
teriorates unless kept well corked, and in a cool place. For 
this reason, although needed in large quantities, it should be 
obtained in the smallest packages (4 oz.), and these should 



DIPH r HER I A — TREA TMEN T. 363 

only be opened as required for immediate use. The 15 vol- 
ume strength is to be preferred. In the early stages of the 
disease, this strength can be used by spray without dilution. 
The oxygen contained in this preparation has a strong affinity 
for all metals except gold, silver and platinum, and hence, the 
atomizer used should consist only of glass and rubber. When 
the peroxide is first used in full strength, it produces a slight 
smarting sensation ; but this is trifling and no irritation results. 
When thrown up the nose it should be diluted one-half 
with water. If by reason of a too copious or too violent irriga- 
tion, the patient should swallow any considerate portion of the 
liquid, no apprehension need be felt, for we often give it in this 
way for its antiseptic influence over the false membrane which 
has been disintegrated and taken into the stomach. It should 
be used as often as the strength of the patient will permit. In 
the early stages this means at least once an hour. 

There are many other local applications which have their 
advocates, but they are not to be compared with those which 
have just been named. Boracic acid, chlorate of potash, bro- 
mine, iodine, bichloride of mercury, and a long list of other 
remedies have been tried and found wanting. They all have 
objectionable features which render them either unreliable or 
unsafe for general use. Every now and again the newspapers 
teem with some old woman's remedy which has been, or seems 
to have been, useful in cases of diphtheria. The laity are much 
given to credit any story of a case cured, even by such apocry- 
phal means, and as these measures are generally harmless, if 
impotent, the best way seems to be to permit their use, under 
protest or without, while other and better accredited remedies 
are being actively employed. 

In case the domestic or empirical remedy is of questionable 
innocency, the onus of responsibility for its use should be 
thrown upon the user. Thus, if one is asked if a certain rem- 
edy or measure of unknown value suggested by the patient's 
friends or nurse may be used, the best disposition to be made 
of the matter is to say, *' Why yes, certainly, use it if you 
choose ; but yon must take the responsibility of doi7ig so. Thus 
we hear all the time about the local application of sulphur, of 
lemon juice, of pineapple juice, etc., and of the most incred- 
ible cures effected by their miraculous powers ; and while the 
experienced physician may know of their utter incompetency, 
it is cruel to deprive an anxious and despairing parent of even 
a ray of hope thus furnished, even though he may know that 
even this ray is purely fanciful. 

Internal Treatment. — The drug which comes the nearest to 
being a true similimum of diphtheria in its gravest aspects is 



364 THE DISEASES OF CHILDREN, 

mercurius, and the physician who achieved the greatest success 
in the treatment of it in the colonial outbreak which marked 
its advent into this country, referred to in the beginning of 
this chapter, was Dr. Douglas, of Boston, who succeeded in 
saving many cases by the heroic use of calomel. It was the 
first time in America that mercury was used in acute inflam- 
matory affections. At the present day it is used by both 
schools of medicine successfully, but of course in very differ- 
ent preparations and doses. Old-school physicians report a 
great many cases treated successfully with the bichloride in 
doses of one-tenth to one-sixtieth of a grain, repeated every 
few hours until the membrane is detached. Others of this 
school still prefer the time-honored '' mild chloride " (calomel) 
in doses of one to five grains every one or two hours till its 
characteristic purgation is produced. Our own school, using 
the same drug in the third, the thirtieth or the one-hundredth 
attenuation, seems to have precisely the same success, which 
demonstrates, as clearly as a single illustration can prove a 
thing, that it is not the quantity, but the specific power of the 
medicine, which renders it curative. The particular prepara- 
tion of mercury (mercurius) which is best adapted to these 
cases is not well settled. Some physicians prefer the cyanuret 
of mercury ; others the iodides, especially in strumous subjects. 
All of the mercurial preparations present a fairly good picture 
of diphtheria. Our own preference is for mere. cor. in cases 
where there is a large amount of exudate, great fetor and also 
great prostration. We prefer the iodide of mercury when the 
glands are much involved and the neck is greatly swollen. It 
is especially useful in scrofulous subjects as already stated, 
and is well adapted to those cases which early show a tendency 
to malignancy. The countenance is livid and the discharges 
from both throat and nose are putrid ; the saliva is profuse 
and stringy. There is also great pain in swallowing. Kali 
bichromicum undoubtedly ranks next to mercurius as truly 
homeopathic to diphtheria. In mild cases or those of moder- 
ate intensity, it often takes first rank. It is especially indicated 
in those cases which show a tendency to laryngeal complica- 
tion. Dr. Richard Hughes, of London, says of kali bich., " In 
nasal diphtheria I find it specific ; in laryngeal, it does all that 
medicine can do." Dr. Mitchell says the special indications 
are : *' Mucous membrane deeply affected and ulcerated ; pain 
in the throat ; painful, difficult swallowing ; stringy, tough 
mucus ; the exudation is of a yellowish or yellowish-white 
color, and is of a firm, fibrous nature, thrown out in large 
quantities, covering both tonsils and tending to extend into 
the nares and larynx. The characteristic difference," he adds,. 



DIPlirHERI A— REMEDIES, 365 

"between kali bich. and mere, iod., is the more fibrinous con- 
sistency of the exudate under kali, while mercury has a softer 
and more pasty pseudo-membrane." Kali should be given in 
solution. Two to three grains of the 3X should be dissolved 
in half a glass of water, and a teaspoonful of this given every 
hour, or every half-hour if the case is urgent. 

In malignant cases, where there is considerable exudate of a 
dirty brown color, of tough consistence, and great fetor of 
breath, we give the kali in trituration, depositing it directly on 
the affected surfaces by means of a powder-blower, repeating 
the operation at intervals of one or two hours until there is a 
manifest amelioration of symptoms. 

The attempt has been made to dispose of the pseudo-mem- 
brane, and thus get rid of at least the outward and visible 
signs of the disease by means of certain digests, such as pep- 
sin and papoid, but without success. All such efforts are based 
upon a very superficial and erroneous idea of the true nature 
and real danger of the affection. It cannot be too frequently 
or too emphatically stated that diphtheria is a systemic or gen- 
eral disease ; in all cases, to a greater or less extent, infecting 
the entire organism, the pseudo-membrane being in some cases 
more prominent than in others, but never in any case consti- 
tuting the entire malady. It would certainly show poor gen- 
eralship — to use an army simile — to concentrate all or most of 
one's forces on a single outpost, while the main body of the 
enemy was known to be in ambush in the immediate vicinity. 

Arseniciivi. — This remedy is not used in diphtheria as often 
as it should be. It is very useful in some malignant forms, ac- 
companied by great debility, pallid countenance, puffiness of 
face and eyes, urine scanty, feeble pulse, acrid discharge from 
nose, very fetid breath and painful deglutition. 

Apis niel, — Uvula elongated and edematous ; puffiness of 
mucous membrane extending onto hard palate; urine scanty or 
suppressed ; burning and stinging dryness of throat ; swelling 
of the cervical and submaxillary glands ; where there is edema 
of the glottis ; fiery redness or puffiness of a purplish tint ; 
very useful in cases of laryngeal diphtheria, when other symp- 
toms as above correspond. 

Arum tripJiyllum. — The indications for this remedy are fetid 
breath and great acridity of discharges from mouth and nose ; 
discharges excoriate and form large crusts about the orifices ; 
diphtheritic deposit excessive and mixed with more or less 
ulceration. The acrid character of the discharges creeping be- 
yond the mucous membrane and affecting the adjacent skin, is 
the key-note for this drug. 

Lachesis. — Malignant cases: exudation worse on left side; 



366 THE DISEASES OF CHILDREN. 

mucous membrane livid ; great difificulty and pain on swallow- 
ing; great weakness; delirium well marked; bad-smelling 
stools ; ulceration of mucous membrane. The marked charac- 
teristics of lachesis are lividity of mucous membrane ; inflam- 
mation worse on left side, and painful deglutition. 

Ferruin per chloride. — The tincture of the perchloride of iron, 
as well as the muriatic tr., are used extensively by the old 
school of practice, and apparently with good results. They 
use these iron preparations both locally and internally. There 
is no doubt that iron, if presented in an assimilable form, may 
counteract, to some extent, at least, the anemia which attends 
all cases of diphtheria ; but even as a tonic our ferrum met. 
and ferrum phos. are superior to the crude tinctures. 

Dr. Hale suggests that as muriatic acid is of known value in 
these cases, that it is the combined acids in these iron prepa- 
rations that render them useful, rather than the metal itself. 
The indications for them are not clear ; at least they are not 
clearly defined as compared with other remedies already spoken 
of, or to be mentioned hereafter. They may perhaps be used 
with advantage intercurrently with other medicines more spe- 
cifically indicated. 

Phytolacca. — Is very useful incases of mild or moderate inten- 
sity, attended with pain on movements of tongue and neck; adapt- 
ed to cases that in the beginning simulate follicular tonsilitis, but 
with fetor of breath and weakness unusual to this latter dis- 
ease ; in addition to prostration there is drowsiness ; constant 
inclination to swallow ; nausea, vomiting and diarrhea. This 
remedy is of no value in malignant cases. 

M. Teste, of Paris, is a strong advocate of the use of bromine 
in diphtheria. His high standing and large experience in this 
disease entitle his opinion to more than ordinary weight. He 
gives the bromine in solution, the strength of which is one grain 
to one hundred drops of water. Of this he gives two to three 
drops in a little sweetened water every quarter of an hour, or 
less often in mild cases. He also advocates the free evaporiza- 
tion of the medicine in the sick room, both as a further means 
of cure and as a prophylactic for nurses and attendants. 

Treatment of Complications and Sequelce. — It has already been 
stated that next to diphtheritic croup, the complication most to 
be dreaded is heart syncope. It cannot be too strongly impressed 
upon the mind of the reader that the real danger in diphtheria 
— the one factor in the disease that is of graver import than 
any other — is exhaustion of strength (vitality). This is a danger 
that menaces all cases, mild as well as malignant. This danger 
increases, of course, as the severity of the attack increases, and 
it remains a menace even after all visible manifestations of the 



DIPHTHERIA— TREATMENT OF SE^UELyE. 367 

disease have vanished. The peril from suffocation, even in 
laryngeal cases, is small compared with this danger from ex- 
haustion of the vital energies. 

In the most malignant case, nature will ultimately overcome 
her enemy, if the strength can be kept up, and the deposit can 
be arrested. In trying to meet the requirements of imperiled 
cases from this cause, we are handicapped by repugnance to 
food, and the apathy which fails to appreciate the necessity of 
eating. The difficulty of swallowing renders it necessary to 
employ foods and stimulants in the most concentrated form. 
We make bold to say that for the purpose here indicated alco- 
hol is our " sheet-anchor." It should not be given in the form 
of milk punch or ^g'g nog. Wines are of uncertain value ; good 
brandy is difficult to obtain. Old rye whisky will answer a good 
purpose; but in lieu of this, pure (95 per cent.) alcohol will be found 
most available. This should be given in small and repeated doses, 
sufficiently diluted to be easily swallowed. A little sugar may 
be added to render it more smooth and palatable. In very bad 
cases, this should be given to the verge of intoxication. It is 
not only a quick stimulant, it is more — it is one of the best 
antiseptics known. It is interesting to note with what facility 
it dissolves the diphtheritic exudation in the throat, lowers the 
temperature, and calms the pulse. In young children and in- 
fants it should be used tentatively and with due caution ; but 
it is our firm belief that alcohol, when properly used, has saved 
more lives than any other one remedy. When whisky is used 
it should be given in the form of "sling" or*' toddy," i. e.^ 
mixed with hot water and sugar. If alcohol is used in any 
form, it should be given regularly and systematically. It is the 
*' little and often," rather than the toxic dose, that is desired. 
During convalescence the heart should be examined at every 
visit, and if its action is enfeebled or any irregularity is notice- 
able, cactus (or cactina, its active principle), with nux vomica, 
should be given. "■ Digitalis and strophanthus are close ana- 
logues of cactus, and can be given in similar doses ; but they 
are not as well borne by the stomach, being bitter and nauseous, 
while cactus is quite tasteless." — Hale. 

Cactina can be used in tincture, or trituration, or can be in- 
jected hypodermically. A grain of the first centesimal tritura- 
tion is equal to one drop of a good tincture. 

If sudden collapse is threatened, a hundredth of a grain or 
drop of glonoin may be given first, for its immediate effect, 
and the cactus may be given afterwards. If the respiratory func- 
tion is threatened with collapse, a drop or two of ainyl 7iitrite 
may be given by inhalation, and followed by cactus or digitalis 
or veratrum album. 



368 THE DISEASES OF CHILDREN. 

In paralyses that do not immediately threaten the heart, such 
as chorea, sighing respiration, local paralysis of certain muscles 
or groups of rv^\xs>z\^s>, gclserniiini \s> almost a specific. If the 
limbs are paralyzed, strychnia phosphate 2x, a grain three or 
four times daily, may be given until they regain their power. 
In some cases that are slow to recover, we have seen imme- 
diate and steady improvement manifested under the use of the 
faradic current. It should be used daily as strong as can be 
borne without discomfort. 

Intubation and Tracheotomy.— It must be conceded that 
the internal treatment of laryngeal diphtheria has not been 
attended with that success which inspires either hope or confi- 
dence. Cases undoubtedly do recover — enough to encourage 
effort and prevent despair ; but, except in primary cases and in 
robust constitutions, when the false membrane extends from the 
pharynx below the epiglottis and invades the larynx, the recov- 
eries are few and far between. The danger of suffocation stares 
us in the face, and remedies calculated to remove the stenosis 
are too slow of action to meet the emergency. 

Tracheotomy, which has undoubtedly saved many cases of 
membranous croup, is practically inadmissible here, for the tem- 
porary and transient relief of the stenosis is almost certain to open 
the door to <^2^/^-infection through the surgical wound. Besides 
this the shock of the operation is to be considered. Statistics 
of tracheotomy in laryngeal diphtheria do not or have not 
shown a sufficient number of proportionate recoveries to give it 
standing even as a der^iier ressort. 

O'Dwyer's method of relieving the stenosis by means of in- 
tubation has much to recommend it. At the same time, its 
best results are secured only by an expert operator. It is not 
an easy matter to discover the location of the laryngeal orifice, 
and to insert the tubes while an inexperienced nurse or a nerv- 
ous mother is handling a refractory and half suffocated child. 

The best results from intubation are therefore found in hos- 
pital practice ; but there is no reason why any physician should 
not make himself familiar with the operation. A thorough 
knowledge of the anatomy of the parts ; a deftness in the ma- 
nipulation of the requisite appliances ; a little experience on a 
cadaver, and one or two trained assistants are all that are req- 
uisite. Even the most desperate cases have been known to 
recover through this instrumentality, although it must be borne 
in mind that cases requiring or seeming to require intubation 
are, generally speaking, cases that have passed the local mani- 
festations of the disease, and are suffering not only from sten- 
osis, but from general blood-poisoning as well. 



DIPHTHERIA— HTGIENTC MANAGEMENT. 369 

When intubation fails we have no confidence in tracheotomy 
as a last resort. 

Hygienic Management. — Much can be done for these 
cases of diphtheria in an auxiliary and hygienic way. Chil- 
dren who are subject to catarrh or to inflammatory affections of 
the throat should be carefully looked after during epidemics 
of diphtheria. It is just this class of children in whom, at 
any time, the disease may develop spontaneously. Such per- 
sons should avoid crowded gatherings where the air is likely 
to be vitiated, as theaters, public halls, and even churches. 
This is especially important during cold weather, if diphtheria 
be prevalent. In case the disease develops in a family where 
there are others of susceptible age, the greatest care should be 
taken to prevent its spread. 

The diphtheritic contagium is cumulative and the second 
case in a family is apt to be worse than the first. Great cau- 
tion should be used about kissing and fondling a child with 
sore throat, no matter how innoceiit it may appear. Dogs, cats, 
sheep and swine, all have diphtheria, and, hence, are dangerous 
as pets, especially during epidemics of diphtheria. 

A person with this disease should be rigidly isolated. A 
large room on the upper floor should be selected by prefer- 
ence, and with a grate in it, if possible. A southern exposure 
is to be preferred. Measures should be taken to secure plenty of 
fresh air. The window sashes should be open top and bottom, 
and a screen thrown about the bed to protect the patient from 
currents of air. In laryngeal diphtheria the temperature may 
be kept as high as 76° or 80° Fahr., but in uncomplicated 
cases 68° or 70° is better. The greatest care should be taken 
to avoid disseminating the disease by fomites. The sick room 
should be dismantled, and all unnecessary furniture, carpets 
and hangings should be removed. Instead of handkerchiefs, 
bits of old linen or cotton should be used, and burned as soon 
as no longer needed. All earthen vessels should be frequently 
cleansed and disinfected with Piatt's chlorides or chloralum. 
Sheets hung up in the doorways and moistened occasionally 
with these liquids prevent the contagium from disseminating 
itself unnecessarily abroad. 

The diet should be of the most concentrated and nourishing 
kind, and yet great care must be taken not to offend the 
stomach. Everything may depend on the maintenance of the 
digestive powers. Repugnance for foods is often great and 
unconquerable. Only such foods should be urged upon the 
patient as are easily swallowed, and easily digested. Milk, 
beef juice, Murdock's food — any of these may be given, and in 
D.C.— 24 



a 70 THE DISEASES OF CHILDREN. 

case of stomach intolerance the rectum should be used. The 
rule for feeding should be little and often. 

If stimulants are used, they should be given with great 
regularity and system. During convalescence great care must 
be used to avoid over-exertion or exercise that would tend to 
excite undue action of the heart. 



CHAPTER II. 

WHOOPING COUGH (PERTUSSIS; TUSSIS CONVULSIVA). 

Definition. — Whooping cough is an acute disease of the air 
passages, having a specific contagium, and is incHned to be 
epidemic in character. It is distinctively a disease of childhood, 
and its chief characteristic is the spasmodic cough, which, in 
typical cases, comes in paroxysms and is terminated by a long- 
drawn, audible inspiration, called the "whoop" — hence the 
name. It is a disease of most ancient date and of the highest 
respectability, so far as its democratic tendencies are concerned. 
It is one of the few diseases that are not attributed to filth. 
Its cause is unknown. It has been regarded as an affection of 
the stomach, as a species of catarrh, as a neurosis. There are 
those whose temerity is such, that they do not scruple to regard 
it as of microbic origin. The ^^ bacillus tussis convulsivce'' has 
been isolated, cultivated and classified. And yet the latest 
writer on the disease,* says, speaking of the various untenable 
theories held prior to the beginning of the present century : 
" The lapse of nearly a century has not entirely cleared up 
these obscurities as to nature and cause, nor relieved the prac- 
tice of medicine of the odium of polypharmacy in treatment." 

The latest researches in pathology indicate that it has no 
morbid anatomy except in its complications. One attack con- 
fers as much immunity on its victims as does scarlatina or 
variola on theirs — perhaps more so. Sucklings are immune. 
Its principal victims are between six months and six years of 
age — most of them under four. For some inexplicable reason, 
the female sex suffers most, in the proportion, according to 
nearly all authors, of 5 to 4. Girls also suffer more severely than 
boys. Measles and pregnancy predispose to it. It is prevalent 
at all seasons of the year, but more so during the autumn and 
spring. 

Symptoms. — For clinical study, the disease may be conven- 
iently divided into stages. Thus: 1st, catarrhal; 2d, spasmod- 
ic or convulsive; 3d, remission or decline. The first and third 
stages are oftentimes but poorly defined — the former especially 
so. The middle or convulsive stage is also frequently wanting 



• Dr. James L. Whittaker in Pepper's " Text Book," etc. 

(371) 



372 THE DISEASES OF CHILDREN. 

in positive characteristics, no definite ''whoop" being manifest. 
During the first or catarrhal stage, there are no special symp- 
toms that distinguish it from an ordinary cold. The spasmodic 
character of the cough is usually not developed until later, and 
all that can be discovered in the average subject is a cough of 
catarrhal character; but this cough does not yield to remedies 
like that which comes from an ordinary cold. It persists in 
spite of well-chosen and ordinarily successful remedies. In 
many cases, however, the symptoms are more pronounced, and 
it is noticeable that the cough is easily excited by swallowing 
anything of a dry nature, such as crackers or dry bread — any- 
thing, in fact, that irritates the throat. It is also noticeable 
that the cough is inclined to be paroxysmal, especially at night ; 
the eyes are somewhat puffy, and the face takes on a swollen 
and sallow look, as if there were some deeper-seated trouble 
than should come from a transient and trifling cause. An 
examination of the chest during this first stage sheds but little 
light upon the true nature of the disease. Some bronchial 
rales may be heard by aid of the stethoscope, but no more than 
are heard in the incipiency of the mildest bronchitis. As the 
disease progresses, however, the symptoms become more pro- 
nounced ; the cough becomes gradually more paroxysmal, and 
at the termination of each paroxysm, there is an expulsion of 
phlegm from the bronchi, often accompanied with vomiting or 
gagging. As with other febrile conditions, the child may be 
pretty well during the day, with good appetite and little 
indication of sickness ; or, on the other hand, there may 
be considerable fever, accompanied with fits of coughing 
and fretfulness and loss of appetite. Even now there are 
nocturnal exacerbations. While quietly sleeping there 
will be a sudden onset of cough, more or less severe, but 
always enough to awaken the patient and prevent continu- 
ous slumber. Auscultation during the first stage, as already 
stated, may reveal a slight bronchitis or bronchial catarrh affect- 
ing the larger tubes ; but, as a rule, the cough and the general 
symptoms of ill-health are out of all proportion to the physical 
signs. During the day the patient is up and dressed, but be- 
comes restless and anxious just before a paroxysm of cough 
approaches. The child early learns to dread these paroxysms, 
and as soon as one is felt to be approaching he instinctively 
runs to his nurse or mother for support. In their absence, he 
seizes the nearest thing to him, be it chair or table, and clings 
to it tenaciously until the paroxysm is over. The duration of 
these seizures is various, lasting from a quarter of a minute to 
a minute or more. In typical cases the cough is attended with 
flushing of the face and suffusion of the eyes, and each par- 



WHOOPING COUGH— DEFINITION. 373 

oxysm is accompanied with vomiting. During the catarrhal 
stage there is commonly more or less fever ; but many cases 
run their course from beginning to end with no perceptible rise 
in temperature. When fever exists, it is most noticeable at 
bed-time, and the cough is strongly inclined to exhibit its 
peculiarities at night. It arouses the child from the profound- 
est slumber, into which he relapses again as soon as the par- 
oxysm is over. The different stages of the disease are exceed- 
ingly variable in duration. Sometimes the first or catarrhal 
stage lasts but a few days, while in other cases it may last for 
weeks. The stage of decline is especially indefinite. An at- 
tack beginning in the fall or early winter is pretty sure to last 
until the following spring or summer. The cough is greatly 
aggravated by breathing cold air, and sensitiveness to cold 
remains with the subjects of whooping cough for months 
after the disease is apparently over. In the middle or convul- 
sive stage the neurotic element asserts itself and is more or 
less pronounced. The seizures are sudden, and yet the child 
is prone to feel a premonition of its approach — a sort of aura 
which previous experience has rendered recognizable. It is a 
sense of impending danger, or feeling of distress, which impels 
the victim to leave its play or study or meal, as the case may 
be, and seek the most available succor. Thereupon ensues the 
series of expiratory coughs that distinguishes the disease from 
all other affections of the respiratory organs. Goodheart likens 
it to the attack which one experiences when, in swallowing 
liquids, a drop or two gets into the rima glottidis. There is 
the same sudden onset of a number of rapidly succeeding ex- 
piratory coughs, till the face becomes turgid and the eyeballs 
start from their sockets and the eyes run over with tears. 
There is frequently at the termination of such an attack the 
semblance of a whoop or a crow, which is due to the rapid 
influx of air to satisfy the respiratory needs, which have become 
urgent by reason of the successive and exhaustive expiratory 
efforts. 

The paroxysms occur in every grade of frequency and sever- 
ity. They are often so mild as to lose all distinctive character- 
istics, and in other cases are so severe as to cause rupture of 
blood-vessels. Hemorrhages often occur from nose and mouth. 
It is not at all uncommon for subconjunctival hemorrhages to 
occur. The membrana tympani occasionally ruptures and is 
accompanied by bleeding from the external meatus. We have 
a case now under observation Avhere hemorrhage occurred in 
the brain, producing catalepsy. This accident happened some 
five years ago, when the child was two years old. Hernia is 
not uncommon, nor prolapsus ani. Convulsions are also 



374 THE DISEASES OF CHILDREN. 

possible. The frequency of the paroxysmal attacks of cough 
varies all the way from ten or twelve daily, to double or quad- 
ruple this number. The severity of the disease is in direct 
ratio to the number and intensity of the paroxysms. Dur- 
ing the intervals between paroxysms, the child is to all appear- 
ances in perfect health. Even when the attacks of coughing 
are frequent at night, arousing the child from profound slumber 
at short intervals and causing it to struggle fiercely for air, it 
falls asleep again immediately the attack is over, and awakens 
in the morning without a sign of fatigue. 

The expulsion of a quantity of ropy, tenacious mucus at the 
end of each paroxysm of coughing is an essential feature of the 
disease. 

A curious symptom is present in the great majority of severe 
cases, but is incidental rather than essential to the disease 
proper. It consists in the appearance of an ulcer on the fre- 
num linguae. This lesion was observed so constantly as to give 
rise to the belief that it had a causal relation to the disease ; 
but it is now known that it is caused by the friction of the pro- 
truded tongue against the inferior incisors. It is never observed 
in cases that occur in children prior to dentition. 

The paroxysmal stage lasts as a rule from one to four weeks, 
when the interval between paroxysms becomes gradually longer 
and the explosions themselves less severe and prolonged. 
During the stage of decline, however, there may be occasional 
paroxysms of former severity, and it is no uncommon thing for 
these explosions to recur with such original intensity and fre- 
quency as to seem like a veritable relapse. In this way this 
third stage of the disease is often greatly prolonged, lasting 
sometimes as long as a month or more. There are cases in 
which the patient is said never to have recovered from the dis- 
ease. But when cases like these are unduly prolonged, it is 
doubtless due to complications to be spoken of hereafter, such 
as chronic bronchitis, bronchiectasis or tuberculosis. 

It is worthy of note that all during the course of the disease 
any excitement, such as anger or boisterous play, is sure to 
precipitate a paroxysm of cough and intensify its severity. 

Complications. — Whooping cough is liable to innumerable 
complications, and these constitute the really dangerous ele- 
ment in the disease. There is always more or less bron- 
chitis from the first, and the rales which accompany bron- 
chitis are usually so pronounced that they drown all other 
respiratory sounds. Any disease attended with bronchitis is 
also liable to broncho-pneumonia, and hence the latter is by 
far the most frequent of the serious complications of whooping 
cough. 



WHOOPING COUGH— DIAGNOSIS. 37r> 

Convulsions, usually of a clonic character, are very apt to 
complicate the disease, from the congestion of the cerebral 
veins and sinuses, produced by the explosive force of the cough. 
These convulsions, affecting for the most part the external 
muscles, occur most frequently during the second stage of the 
disease, when the cough is most severe, and in infancy more 
often than in childhood. As stated by J. Lewis Smith, the 
gravity of the convulsive attack can be ascertained by observ- 
ing whether or not the patient readily recovers consciousness. 
Its return indicates that there is no serious congestion. On 
the other hand, great and persistent drowsiness, or a semi- 
comatose condition, indicates profound congestion, and perhaps 
even the formation of clots in the sinuses of the brain. Death 
from convulsions is usually preceded by coma. 

The spasmodic closure of the glottis, and the powerful efforts 
of the expiratory muscles, sometimes develop edema of the 
glottis, and sometimes — perhaps more frequently — emphysema 
of the lungs. When the latter occurs, it is usually slight, mar- 
ginal or peripheral, and is marked by dilatation only of the 
air-cells. Occasionally the dividing walls are broken, and the 
air-cells are ruptured, and a pneumothorax developed. 

Vomiting, which is an almost universal accompaniment of 
severe, or even well-marked cases, may be so severe and per- 
sistent as to constitute a true complication. It may result in 
marasmus, or be so severe, lasting into the intervals, as to cause 
collapse. Complications on the part of the nervous system 
are rare. Occasionally a paroxysm is followed by strabismus, 
dilatation of pupils, or blindness. 

Diagnosis. — Whooping cough, as already stated, occurs in 
paroxysms or explosions. The series of expiratory coughs, 
terminating in an audible inspiration and the expulsion of 
phlegm and mucus from the mouth ; the anxiety shown by 
the patient whenever a paroxysm is impending ; the puffy eye- 
lids ; the sallow, pallid countenance ; the tendency of the 
cough to group itself into paroxysms ; the aggravation of the 
cough at night and by eating any dry food ; the attendant 
tendency to vomit with the cough — when these symptoms or 
many of them are present, there is no difficulty in establishing 
the diagnosis. 

During the first stage, if the history of exposure be obscure, 
the diagnosis is often in doubt, and in mild cases must remain 
so until the characteristic whoop is developed. Even now 
there are grounds for confusion. It is allowed by all writers 
that chronic diseases of the bronchial glands sometimes pro- 
duce a noisy, paroxysmal cough, very like pertussis. But in 
such cases there is an absence of any definite stages and they 



376 THE DISEASES OF CHILDREN. 

occur sporadically, not in epidemics. There is evidence of 
associated lung disease, and a history of wasting, long before 
the development of the cough. 

Prognosis. — The prognosis in whooping cough depends 
somewhat upon age and constitution, but more upon treatment 
and management. It seems strange to read in the works of 
late authors that this affection has ever had so large a mortality 
as is therein mentioned. Thus, it is stated by Dr. Whittaker 
that out of 500,341 deaths occurring in England in one year^ 
10,318 deaths were from whooping cough. Again, he states 
that in one decade in New York, wherein 4,062 deaths occurred 
from typhoid fever, there were 4,094 deaths from this disease. 
In this city (Chicago), during 1892 there were 1,489 deaths 
from typhoid fever and 164 deaths from whooping cough. 
This year, however, is not a fair criterion by which to judge of 
the relative mortality from the two diseases. Typhoid was 
very prevalent and unusually fatal, while whooping cough was 
mild in its attacks and not very prevalent. 

That it is not a trifling ailment is shown by the relative 
mortality from it, as compared with scarlet fever and measles. 
The mortality from the three diseases was (1892) as follows: 
Scarlet fever, 382; measles, 185 ; whooping cough, 164. Un- 
der homeopathic treatment, this disease usually runs a mild, 
although sometimes tedious, course, and its complications and 
sequelae are neither common nor severe. This is especially 
true if the cases affected with some dyscrasia, be eliminated 
from our statistics. 

The greatest mortality is always in young infants. In chil- 
dren of four or five years of age, the mortality is small. Biermer 
made a grand average of the established mortality rate, based 
upon the statistics of many authors, at J, 6 per cent. 

The most frequent causes of death are suffocation due to 
spasm of the glottis, broncho-pneumonia, hemorrhages and 
marasmus. The more numerous the seizures in the twenty- 
four hours, the more grave is the disease. When they reach 
as high as fifty or sixty paroxysms in a day, the disease 
assumes a special gravity. 

Treatment. — There is no remedy in our own or any other 
school of practice which acts as a prophylactic in whooping 
cough. Nor is there any remedy that can properly be regarded 
as a specific in the affection. The treatment to be successful 
must be symptomatic, and regard must be had for the genius 
epidemicus. In some epidemics a remedy may frequently be 
found that will abort some cases, abbreviate others, and amel- 
iorate all. Thus, Dr. Winterburn states that in a widespread 
epidemic, occurring in Brooklyn some years ago, he used 



WHO OP /JVC C O UGH— TREA TMEN T. 877 

gelsemium almost exclusively, and with the most satisfactory- 
results. 

This drug is a prince among nervous and especially spas- 
modic affections, and ought, a priori, to be a useful remedy in 
the spasmodic stage of the disease at all times ; and yet we 
have failed to find it mentioned in connection w^ith whooping 
cough by any author whom we have consulted. Dr. W. A. 
Edmonds, of St. Louis, in his " Treatise on Diseases of Chil- 
dren," says that in the early years of his practice he achieved 
considerable local reputation by using belladojma and droscrUy 
either simultaneously or in combination. He says: ** The form 
of combination was to medicate pellets No. 25 with ist deci- 
mal dilutions of the two named remedies, and prescribe two to 
four, six, or eight pellets, according to the age of the child, at 
intervals of about two hours at first, and when better every 
three or four hours. . . . This prescription," he further 
states, *^ I have found remarkably successful in the treatment 
of whooping cough. Sometimes it has seemed to cut it short; 
it rarely fails to induce a most comfortable palliation." 

We have, ourselves, used, with great satisfaction, a similar 
combination of ipecac and Jiyoscyamus, and we feel sure that we 
have many times aborted an attack of whooping cough by 
their combined use in the manner above indicated. Probably 
a more scientific and perhaps more successful method would 
be to give the belladonna or the hyoscyamus in the febrile or 
catarrhal stage, and the drosera or ipecac afterwards. The use 
of remedies during a paroxysm is out of the question. What- 
ever therapeutic measures are adopted, they must be brought 
into use during the intervals, and must be used persistently 
and patiently in order to test their utility. In addition to the 
remedies to be considered hereafter, according to their symp- 
tomatology, various inhalents have been used, and apparently 
with some degree of success. Among the more prominent of 
these are turpentine, thymol, carbolic acid, cocaine, tar, benzole, 
sulphuretted hydrogen, and illuminating gas (carburetted hy- 
drogen). Vapo-cresolene, which is one of the products of coal- 
tar, has considerable repute, and we have sometimes thought 
that it did ameliorate the paroxysms; but we have been unable 
to discover any permanent good from any of these volatile 
remedies. On the other hand, they are open to serious objec- 
tions — at least, many of them are — because they fill the air 
with pungent fumes, that make it almost intolerable for the 
attendants, and must of necessity vitiate the air breathed by 
the patient. 

In lack of indubitable evidence of merit in the use of such 
malodorous compounds, it is better to give the child plenty of 



378 THE DISEASES OF CHILDREN. 

fresh air to breathe, and trust the rest to nature and remedies 
internally administered. 

Therapeutics. — In addition to the drugs already mentioned, 
there is a long list of remedies whose homeopathicity to cer- 
tain phases of the disease is vouched for by unquestionable 
authority. Raue, in his ** Special Pathology and Therapeutic 
Hints," gives the symptomatology of over seventy drugs. 
Lilienthal contents himself with thirty-four. We shall limit 
ourselves to a half-dozen or so of the principal remedies, which 
have received personal verification of their therapeutic value. 

As regards the complications and their treatment the reader 
is referred to the special chapter or section bearing upon the 
disorders, regardless of their origin. There is no special reason 
why bronchitis, broncho-pneumonia, or convulsions should be 
treated differently \^hen arising in the course of whooping 
cough than if they arose idiopathically, and we thus avoid 
needless repetition. 

Belladonna. — Cough so spasmodic that patient cries ; great 
congestion of head and face, which causes considerable coryza 
and epistaxis ; short, rough, hollow cough, caused by tickling 
sensation in larynx ; dry, spasmodic cough, worse at night ; 
touching the throat or moving it excites the cough ; the breath- 
ing is short, hurried and labored ; dyspnea ; involuntary passage 
of stools. 

Corallium Rubrum. — Paroxysms of convulsive coughing ; 
cough excited by deep inspiration ; rapid succession of violent 
paroxysms of coughing, so violent that child stops breathing, 
grows purple in the face, and becomes exhausted, followed by 
vomiting of large quantities of thick, tough mucus ; paroxysms 
increase in frequency towards evening. 

Cuprinn Met. — Most useful action is in the spasmodic stage ; 
face and lips dark blue, almost black ; expectoration of blood- 
tinged, putrid mucus, especially in morning ; cough caused by 
mucus in the trachea ; cough occurs in paroxysms which are 
violent and long lasting; paroxysms so long that child loses its 
breath, and is thrown into convulsions with purple or black 
face ; cough aggravated by eating solid food, but liquids amel- 
iorate the paroxysms. 

Drosera — The paroxysms of coughing follow each other so 
quickly that child cannot get his breath ; cough causes a feeling 
of constriction in the chest, which is relieved by pressing on 
the stomach ; cough is worse after midnight and is followed by 
retching and vomiting, and cold clammy perspiration ; epistaxis 
frequently follows the paroxysms of coughing. 

Gelsemium — Paroxysms of hoarseness and coughing from 
tickling and dry roughness of the fauces ; severe, convulsive. 



WHO OPING C O UGH— THE A THEN T. 379 

spasmodic cough ; soreness of the chest when coughing ; heavy 
and labored respirations ; expirations sudden and forcible. — 
E. M. Hale. 

Hyoscyamtis. — Constriction in throat causing difificult swallow- 
ing, especially of liquids ; great thirst, but drinks little at a 
time ; at night the cough is dry and spasmodic, aggravated by 
lying down, and better when sitting up ; face dark red, bloated 
and distorted. 

Ipecac. — Aversion to food of all kinds, with vomiting of food 
and some bile ; peevish and irritable, with face dark and anxious 
looking ; urine scanty and bloody ; breathing difficult, with rat- 
tling in chest and expectoration of bloody mucus ; cough brings 
on a vomiting spell, with difficult breathing and epistaxis of 
bright-red blood ; cough worse at night, with copious hemor- 
rhages from nose and mouth ; dyspnea ; face blue and body 
rigid. 

Stipp, of Nuremburg, has recently introduced to the therapy 
of the old school a new remedy, which is by many believed to 
be almost a specific for this disease. It is bromoform. It is 
used safely, so it is said, in doses of from one to five drops, 
according to age, repeated three or four times daily. In large 
doses it has produced narcosis. In Senator's polyclinic one 
hundred cases were treated by Lilienthal, who claims that it 
rendered the cases milder in the course of a few days. A New 
York physician, who treated fifty-one cases with it, claimed that 
it surpassed all other remedies in its curative properties. The 
duration of the treatment was from ten to thirty days ; and 
cure occurred in 75 per cent, of the cases in from two to three 
weeks, *' if there were no complications." 

Hygienic Treatme?it. — A child with whooping cough should 
be kept indoors in inclement weather, and allowed proper 
freedom to enjoy the fresh air in mild and suitable weather. 
The clothing should be of woolen ; the diet should be of the 
most wholesome and concentrated character consistent with good 
digestion. It must not be forgotten that much aliment is lost 
through vomiting in bad cases, and marasmus is one of the for- 
midable sequelae. Meat broths, milk, and eggs — the latter, of 
course, in older children — are the best articles of diet. In slow 
convalescence, change of climate often works wonders. The 
temperature of the house or the rooms of a whooping-cough 
patient may be kept warmer than would be advisable in most 
other affections ; 70° or 72° is none too warm, but a uniform 
temperature in this disease is very desirable. 



CHAPTER III. 

PAROTIDITIS (parotitis; MUMPS). 

Definition. — Mumps is an acute and painful inflammation of 
the parotid glands. It is contagious, but not infectious. It is of 
brief duration, and but little gravity, except as it involves other 
and remote organs. It is inclined to be epidemic. A similar, 
although probably not identical, inflammation of the parotids, 
is of frequent occurrence in the course of typhus, typhoid and 
septic fevers ; but in the latter cases suppuration of the glands 
is apt to supervene, which is not true of mumps proper. It 
is very prone to precede or follow outbreaks of the exanthemata, 
and there is rarely an epidemic of any of the diseases of child- 
hood, without some cases of mumps. It is mentioned by all 
of the older medical writers, and is, without doubt, a disease of 
great antiquity. It is most prevalent in the first quarter of 
the year, and affects males more frequently than females. 

The two extremes of life are practically exempt. The period 
showing the greatest susceptibility is from two to ten years. It 
is very apt to prevail epidemically where a considerable num- 
ber of people are herded together. Thus, boarding-schools, 
jails, orphan asylums, and especially barracks, are often in- 
vaded, and when this is the case it is pretty sure to affect all 
who have not had it previously. One attack, if bilateral, affords 
security from further infection. The disease sometimes attacks 
the lower animals, especially dogs ; and it is possible that it 
may be by them communicated back to man, and the spread of 
the contagium be thus promoted. Poore declares that " a boy 
aged seventeen, affected with mumps, and five days later with 
inflammation of the testicle, which suffered atrophy, communi- 
cated the disease to a dog, his constant companion and bed- 
fellow. The dog began to show symptoms in fourteen days 
exactly like those of his master, including subsequent involve- 
ment of the testicles, which likewise suffered atrophy. Thence- 
forth the dog took no pleasure in the society of other dogs, 
which he seemed to shun, and in his disgust forsook his old 
master for a new one."* 

Pure mumps has no definite lesion and no morbid anatomy, 



* Pepper's " Text Book," p. 305. 

(380) 



PARC TID I TIS— S 1 'MP TOMS. 881 

except a tBansient hyperemia, which subsides during resolution, 
leaving no trace behind. It is liable, however, to affect neigh- 
boring glands, and the connective tissue between and around 
them. The total duration of parotiditis is, in mild cases, from 
five to seven days, and in others it may last double this length 
of time. Rarely, but sometimes, the tonsils are also tumefied. 

Symptoins. — Ordinary mumps has no premonitory or pro- 
dromal stage. It commences with tenderness in the parotid 
region, followed soon after by tumefaction, w^hich gradually 
increases until it fills the depression under the ear and extends 
forward and upward into the cheek, and downward to a greater 
or less extent upon the neck. As a rule the color of the skin 
is unaltered, but occasionally there may be some redness over 
the parotid. There is a dull, aching pain whenever the mastica- 
tory muscles are used ; hence, anything which excites an unu- 
sual flow of saliva, like acids, is attended by increased discomfort. 
The disease is attended with considerable malaise rather than 
downright illness. In many cases the temperature remains 
normal although it sometimes rises as high as 102° or even 
higher. 

The swelling reaches its maximum from the third to the 
sixth day. At this time, the most prominent point is immedi- 
ately under the lobe of the ear which it presses upward and 
outward. The tumor which is formed is firm, but elastic, and 
has a doughy feel, very different from the hard and unyielding 
character of an induration. 

Not only is mastication painful when the disease is at its 
height but talking is attended with difficulty, causing the 
patient to mumble. This is supposed to have given origin to 
the name under which the affection is most commonly known. 

In most cases parotiditis is double ; it commences on one 
side, more often the left than right, and in from one to four 
days the opposite gland is involved. In those exceptional 
cases in which only one gland is affected, the opposite one 
may be the seat of the disease at some subsequent period. 
The proportion of cases in which only one parotid is affected, 
as compared with those in which both are involved, is stated 
to be as one to ten. 

Occasionally in double mumps, the swelling is so great as 
to extend from one side to the other in a huge, continuous 
double chin. 

Complications. — The chief danger in mumps arises from the 
fact that the swelling of the parotids sometimes abates sud- 
denly, and coincidently, in the male, the testicle, epididymis and 
tunica vaginalis become inflamed ; while in the female, the 
mammary glands, ovaries, or the labia majora are the seat of 



382 THE DISEASES OF CHILDREN. 

the so-called metastasis. These metastatic inflammations are 
more common about the age of puberty than they are either 
earlier or later. Occasionally they occur without the usual 
subsidence of the parotid swelling. The period when this 
complication is most likely to arise is uncertain. Dr. Dake re- 
cords twelve cases in which the orchitis began on the seventh 
day in six cases ; on the eighth day in four, and one each on the 
ninth and first. 

The orchitis usually subsides within a few days, but in 
exceptional cases it may lead to persistent hydrocele and atro- 
phy of the testis. Whenever the disease is thus complicated 
there is a sudden rise in the temperature, and usually rigors are 
present. The constitutional disturbance may be severe, and 
the high fever may be attended with delirium. 

Meningitis is another complication which is said to occur in 
the course of mumps, but it must be very rare, as most writers 
do not mention it. We have never seen it in this connection. 

Diagnosis. — The only affection with which parotiditis is 
likely to be confused is that symptomatic inflammation of the 
glands which is liable to occur in diphtheria, scarlet fever, or 
some other of the essential fevers. But in the latter case the 
swelling is hard like cartilage ; is circumscribed, and does not 
invest the ear ; the swelling is red instead of waxy, and there is 
a manifest tendency to suppuration, which is not the case in 
true mumps. It should be remembered, however, that essen- 
tial mumps may involve the submaxillary or even the cervical 
lymphatic glands and leave the parotids untouched. While 
such cases are exceedingly rare, it is well to bear the fact in 
mind, in order not to make a mistake. 

Treatment. — In ordinary cases the treatment is exceedingly 
simple and consists principally in hygienic meaures, which may 
conduce to the comfort of the patient, and the avoidance of 
cold, which might tend to compHcations. The diet should con- 
form to the patient's inability to masticate, and consist of 
broths, milk or other easily digested liquids or semi-soHds. 
Soothing embrocations may be made to the swollen glands, to 
alleviate the pain and tenderness of the parts. Nothing should 
be used, however, of a repellant character, nor should the neck 
be swathed too warmly with either wool or cotton. In case 
there is considerable fever aconite or belladonna will be service- 
able; and in case of orchitis, the recumbent posture must be 
observed. Mercurius should be given if the glands show any 
tendency to permanent enlargement, or auruin muriaticum. 

The patient should remain indoors until all swelling has sub- 
sided, and if the testicle has been involved he should wear a 
suspensory bandage for some weeks after apparent recovery. 



PART" VII- 

AFFECTIONS OF THE HEART. 



CHAPTER I. 

POSITION, ANATOMY, AND FETAL CIRCULATION. 

Position. — The heart in a child occupies a position somewhat 
higher in the thorax than that of an adult. The auricles are 
on a line with the second intercostal space, the right extending 
beneath the sternum and almost to its right border. The 
right ventricle is beneath the sternum and to its left ; its lower 
border is on a line with the head of the sixth costal cartilage. 
The left ventricle lies between the third and fourth intercostal 
spaces, and beneath the fourth rib. The position of the apex- 
beat differs from that of the adult. The apex is much higher 
and nearer the nipple, and in some cases the nipple pulsates 
synchronously with the apex-beat. This higher position of the 
apex-beat may be due partly to the distention of the stomach, 
and the large size of the liver at this period of life. The apex- 
beat descends in position as the child grows older. In children 
of six years it is generally close to the nipple, while at the age 
of twelve it is an inch or more lower. The base of the heart is 
usually found posteriorly at the fifth dorsal vertebra. The 
anterior surface of the heart is removed from the chest wall by 
the lungs. They cover almost all of it except the extreme 
point ; the tip of the left ventricle and the lower part of the 
right ventricle only are accessible for physical diagnosis. The 
accessible portion forms a triangle having three points, namely : 
(i) the apex-beat just below the nipple ; (2) the junction of the 
sternum with the ziphoid cartilage ; (3) the junction of the left 
costal cartilage with the sternum. All the four valvular open- 
ings in the heart of a child lie in close proximity within a space 
half an inch square. The mitral valve will usually be found at 
the left border of the sternum, on a level with the upper border 
of the third costal cartilage. The tricuspid lies more under the 
sternum, slightly in front and a little lower. The valves of the 
pulmonary artery are found opposite the lower margin of the 

(383) 



384 THE DISEASES OF CHILDREN. 

second interspace. The aortic opening is slightly lower in an 
oblique direction. For a definition and description of the 
normal sounds of the heart, the reader is referred to the classi- 
cal text-books. 

The study of a case of suspected disease of the heart in a 
child is beset with difficulties not met with in an adult. 

Method of Study. — If you commence to examine immediately 
after the child is prepared by removing the clothing, the sight 
of the instruments will stir up the circulation to such an extent 
that you cannot make a correct diagnosis. While the child is 
being quieted and growing accustomed to your presence, inquire 
into the previous history. Has your patient had scarlatina, 
measles, rheumatism, or any diseases with a known tendency 
to cause endo- or pericarditis ? Observe the appearance of 
the skin, if there is a normal capillary circulation, especially 
about the face and finger-nails ; the expression of the face ; the 
presence of dropsy or anasarca ; the condition of the respira- 
tion ; the presence of cough ; the appearance of the alae nasi 
and the color of the mucous surfaces. First, notice by inspec- 
tion if the apex-beat is a normal position. By palpation with 
the tips of the fingers observe the apex-beat. It should be 
limited in area, well defined and punctated. It should give 
evidence of a first and second sound ; the former by a dull, 
long vibration, the latter by a short and distinct impulse 
against your finger tips. 

Percussion of the heart of a child, unless it is soporose or 
very docile, is very difficult, requiring great skill and tact. The 
patient should sit upright ; commence at the middle of the left 
clavicle and proceed downward until a dull sound tells you the 
upper border of the heart is reached. Then percuss from the 
right side of the sternum on a level with the fourth rib, directly 
across the bone, until at about its left edge you find the 
dullness which shows the heart is reached. In both cases, con- 
tinue across the area of dullness until a clear note is heard, 
showing the lung is reached. 

You will find, however, percussion so unsatisfactory that you 
will learn to rely almost wholly on auscultation as a means of 
diagnosis. The two best stethescopes are Soule's, and Edwards'. 
The rubber vacuum cup of the former adheres and does not 
need to be pressed against the skin, a process decidedly ob- 
jected to by children. Edwards' bin-aural is very light and is 
the best of the kind. 

Place the child in an upright position. Apply the stethescope 
closely to the bare skin. The auscultator's head should not be 
too low, this is very essential. You will then detect two sounds 
very different in character. The so-called first sound is low. 



THE HE A R T—FE TA L CIR C UL A TION. 385 

dull, booming and seems close to the ear; the second sound is 
short, abrupt, winging or flopping. These two sounds in chil- 
dren are audible over the entire region of the heart, and in fact 
all over the thorax, but the sounds are heard most distinctly 
over the seat of their production. 

Full inspiration lessens the sounds very materially ; full ex- 
pirations increase the extent over which they may be heard. 
Note whether the sounds are obscure or clear, the periods of 
pause, or any change in rhythm. Remember that the normal 
heart of a child may beat irregularly or intermittently ; but that 
such arythma is always suspicious. If the heart is not diseased, 
it may be the brain or liver, or may arise from some intestinal 
disorder. 

TJie Fetal Circulation. — Owing to certain differences which 
exist between the fetal and adult heart, the circulation of the 
blood in the fetus in utera differs from that of the child after 
birth. This fetal circulation should be understood and studied, 
or you will not be able to appreciate congenital diseases and 
malformations of the heart. 

" The following is a brief, but yet explicit, resume of the 
fetal circulation : Blood is conveyed through the umbilical 
arteries, which are terminations or branches of iliac arteries, to 
the placenta, where, within the villi of the chorion, the inter- 
changes with the maternal blood take place. After being thus 
renovated and recharged with oxygen, it collects within the 
umbilical vein from innumerable branches, and passes back 
through the umbilical cord to the liver. The blood thus re- 
turned to the fetus is arterial, and that which passed through 
the umbilical arteries, venous ; but it is so in a modified sense 
only. After reaching the liver, on its return from the placenta, 
a part of it first circulates through the liver, and then passes 
out through the hepatic veins, while the rest goes through the 
ductus venosus into the inferior vena cava, and both of these 
streams uniting in this vessel, continue on to the right auricle. The 
two columns of blood, that is, the blood passing into the vena 
cava from the hepatic vein and from the ductus, join the stream 
w^hich has been collected from the lower part of the body, and 
mix with it. In early fetal life the inferior vena cava opens at 
the septum of the auricles into both cavities, though the chief 
part of the blood enters the left, owing to the increased devel- 
opment of the eustachian valve. Subsequently this valve becomes 
smaller, and by the increased development of the valve guard- 
ing the foramen ovale, the current is turned more and more 
into the right auricle. In this cavity the blood is partly mixed 
with that which enters from the superior vena cava, and a part 
of it descends into the right ventricle, whence it passes, in part, 
D.C.— 25 



386 THE DISEASES OF CHILDREN. 

through the pulmonary artery into the lung tissue. No proper 
pulmonary circulation having yet been established, only about 
half the blood contained in the right ventricle enters the pul- 
monary artery, while the other half enters the descending aorta 
through the ductus arteriosus. The imperfectly developed 
pulmonary veins convey to the left auricle but a small quantity 
of blood, the chief supply being received from the right auricle 
through the foramen ovale, through which passes the main 
stream from the inferior cava. From the left auricle the blood, 
which is semi-arterial, descends into the left ventricle, and 
thence into the first division of the aorta. By virtue of this 
movement the head and upper extremities are supplied, 
through the carotid and subclavian arteries, with thn blood 
which has been but little deteriorated in quality, and escapes 
the more venous current from the right ventricle through the 
ductus arteriosus." — Leavitfs Obstetrics. 

''The establishment of independent circulation takes place 
as soon as the child is born. The first act of the new-born babe 
is a lusty cry which inflates the lungs, and, in consequence, 
dilates the pulmonary arteries. As a sequence, the greater part 
of the blood in the right ventricle is at once distributed to the 
lungs, where it becomes changed from venous to arterial blood, 
and is returned through the pulmonary veins to the left auricle. 
The left auricle now receives more blood than it has been 
accustomed to, the right less, and, owing to arrest of the 
placental circulation, the umbilical veins are inactive. We now 
find that the pressure of the blood in the two auricles is equal- 
ized, which aids in the closure of the foramen ovale. 

*' The blood no longer finds its way from right to left auricle, 
but into the right ventricle, and thence to the pulmonary 
artery. The ductus arteriosus becomes impervious, and soon 
collapses. The blood in the descending aorta does not find its 
way into the hypogastric arteries, but directly into the lower 
extremities, and adult circulation is established." — Keating on 
the Hearts of Children, 



CHAPTER II. 

CONGENITAL DISEASES OF THE HEART. 

"After birth the foramen ovale soon becomes permanently 
closed, probably by contracting adhesions to the edges of the 
aperture. The umbilical arteries and veins and the ductus 
venosus speedily collapse and become impervious. Any one of 
these structures may remain pervious and constitute some of 
the circulatory anomalies due to arrested development or want 
of proper completion in the stages of change from fetal to adult 
circulation. The foramen ovale sometimes remains open or 
imperfectly closed. Some observers state that the valve is 
never completely obliterated until the eighteenth month or 
second year of extra-uterine life. In many cases, the patulous 
foramen is secondary to defects in the mitral valve, allowing 
regurgitation or obstruction in the large arterial trunks, aorta, 
and pulmonary artery. A patulous foramen is more frequently 
associated with obstruction or narrowing of the pulmonary 
artery. Narrowing of the tricuspid orifice would also be a di- 
rect cause of patulous foramen ovale, but primary defects in 
the tricuspid orifice, causing narrowing or stenosis, are very rare ; 
in fact, it is rare that we see it even in combination with other 
defects. It may be, and generally is, due to narrowing of the 
pulmonary artery. As a rule, the direction of the blood-cur- 
rent, in cases of patulous foramen ovale, is the same as that 
during fetal life, i. r., from right to left auricle ; but cases have 
been noted in which the direction of the blood-current was di- 
rectly opposite from that which pertains during intra-uterine 
life, i. e., from left to right." — Keating ajtd Edwards. 

I shall not mention other malformations, as they are not 
amenable to treatment, and cannot be included in a work of 
this scope. For a study of those the reader is referred to that 
admirable treatise on "Diseases of the Heart in Children," by 
Keating and Edwards. 

The symptoms of these congenital defects should be studied 
in order to make a diagnosis. Many children, at birth, present 
an intensely blue discoloration, which more or less speedily 
passes away, depending upon the voluntary or artificial estab- 

(3<S7) 



B88 THE DISEASES OF CHILDREN. 

lishment of respiration, whereby the circulatory organs are ren- 
dered active. If the discoloration continues, sonne congenital 
malformation of the heart or great vessels should be suspected. 
So, also, if a child, a few weeks after birth, develop cyanosis ; 
it is almost positive proof of some congenital defect. If due 
to that cause a murmur may be heard, together with quickened 
pulse and rapid heart action. If the defect is compatible with 
life, the patient may live several years, and even pass through 
youth to manhood. Keating mentions the case of a girl who 
remained in bed until sixteen years old. I have known several 
men, aged respectively eighteen, twenty-four and thirty, whose 
foramen ovale never closed. They were slim and poorly nour- 
ished, and never became capable of much physical exertion. 
Cyanosis may not always be present. Dyspnea on exertion 
is always present. The temperature is often sub-normal, espe- 
cially when the patient nears dissolution. Cough is almost 
always present. There may be chronic bronchitis with bloody 
expectoration. The subjects are prone to congestion of the 
spleen, liver and kidneys, and to dropsy with albuminuria. 
The fingers may be clubbed, nails bent, or ulcerated around 
the margin. 

Treatment. — We can do but little in the treatment of con- 
genital defects. The main aim is to keep up the integrity of 
the cavities of the heart, just as we should in cases of threat- 
ened hypertrophy with dilatation in adult life. The chief 
medicines are cactus, digitalis, nux vomica, and phosphate of 
lime. Rest, both of body and mind, is imperative, when we 
fear imperfect compensation. The child should be fed (if not 
nursing) on good, nutritious, muscle-making food. The posi- 
tion, when lying, should be on the back or right side. A warm, 
dry or moist climate is preferable. I sent two patients to 
South Florida, who lived there comfortably when they could 
not live so in the North. 



CYANOSIS. 

This is sometimes called the "blue disease." It is one of 
the most constant and prominent symptoms of congenital 
heart disease. It may, however, be acquired, and be caused 
by endo or pericardial inflammation ; it may be present in 
hydropericardium, or any active pericardial effusion. Dr. Wa- 
ters {^Phil. Med. Examiner, 1850) relates a case in which cyano- 
sis developed in a child aged six during an attack of measles, 
and remained persistent. Another case is reported in which a 
six-months babe received a severe fall, and was cyanotic always 



THE HEART— Cl'ANOSIS. 389 

afterwards. Many other such cases are on record. Cyanosis 
may be caused by a stasis in the venous current independently 
to a certain extent of the admixture of venous and arterial 
blood, but if the latter occurs the color will be a great deal 
darker. It is a strange fact, however, that there may be a 
complete mixture of the blood without any cyanosis whatever. 
Any cause which prevents a return of venous blood to the 
heart, or its proper oxygenization in the lungs, will cause 
cyanosis. All the cardiac poisons which paralyze the heart 
will cause a degree of cyanosis. J. Lewis Smith ("Diseases 
of Children") says cyanosis is more common in male than in 
female children. He also says that large cities return the 
largest proportion of cyanotic cases. It is found principally 
among the lower classes, who have a perpetual struggle for 
existence, living in low, damp, ill-ventilated rooms, with scanty 
food and clothing, and with wretched hygienic surroundings. 
Such conditions inevitably result in imperfect, or arrested 
development of children, even in the uterus. 

Cyanosis due to congenital defects may not appear at birth. 
Smith gives 41 cases; in 3 it appeared in two weeks, I at three 
weeks, 2 at one month, 7 from one to two months, 5 from six 
to twelve months, 3 from one to two years, i from five to ten 
years, 6 from ten to twenty years, i from twenty to forty years, 
and I over forty years. This shows that a congenitally crip- 
pled heart may, in some cases, carry on life many years, con- 
forming itself to a disordered blood circulation, and continue 
to grow in strength until some accident or disease " breaks the 
compensation." 

Treatment. — After cyanosis once appears and is due to a 
structural cardiac defect, a cure is very rare, but considerable 
improvement may occur. Rest, good nourishment, avoidance 
of all excitement, bodily or mental, with a warm climate or 
warm clothing, must be insisted on. The medicines which 
cause venous stasis with imperfect oxygenization of blood — or, 
to be more exact, which cause cyanosis primarily — as lauro- 
cerasus, hydrocyanic acid, cyanuret of potash, etc., are not in- 
dicated in this disease. Only those are useful which, by their 
action on the muscular fibers of the heart, tend to prevent 
dilatation of its cavities. The most prominent of them are 
digitalis, cactus, strophanthus, anhalonium, spigelia, spongia, 
convallaria, coffea, etc., given in doses suitable to the age of 
the child. If the blood is actually impoverished, ferrum and 
manganese, with ignatia and nux vomica, should be given, and 
those meats which are rich in blood-making material. Con- 
stipation or hepatic torpor must not be allowed to exist, as 
improvement will be greatly retarded thereby. 



390 THE DISEASES OF CHILDREN. 

VALVULAR DISEASES. 

Valvular lesions in children are usually caused by rheumatic 
endocarditis. More rarely are they caused by, or occur during 
the progress of, Bright's disease. As before stated, they may 
be congenital. They occur during chorea, and it is still a dis- 
puted question whether chorea is altogether of rheumatic origin 
or often caused by a specific bacilli. If the latter, we need not 
be surprised to find that they invade the valves of the heart. 

The diagnosis of valvular disease of the heart in children is 
governed by the same rules as for the adult, with the exception 
that the position of the heart in health and disease is higher in 
the thorax in children. This I have mentioned on previous 
pages. In vol. 2 of '* The London Homeopathic Hospital Re- 
ports," 1892, is an excellent paper by Dr. E. A. Neatby, assistant 
physician, containing ''original investigations respecting the posi- 
tion of the heart's apex-beat in children." The following summary 
of the conclusions were based on two hundred measurements in 
cases where no deformity of the chest was present, and no dis- 
ease of the heart or lungs. The age limit was fourteen years. 

" I. That the heart's apex-beat is situ'ated more externally in 
children than in adults. 

2. That it is quite exceptional, if not abnormal, for it to be 
found external to the nipple line. 

3. That the relative distance of the apex-beat from the 
nipple line varies rather with the age of the subject than with 
the size of the thorax. 

4. That the more external position in children is explained 
by the large size of the heart and by the small transverse meas- 
urement of the chest in these subjects. 

5. That the size and state of distention of the abdominal 
organs furnish a less constant cause for variation of the position 
of the heart. 

6. That the heart is situated also at a higher level in the 
thorax than in adults, and that this is especially the case in 
infants. 

7. That the apex-beat is felt at a higher level in the recum- 
bent than in the erect posture. 

8. That the heart's sounds are more widely audible in the 
chest of the child than of the adult. 

The most direct method of diagnosis of valvular disease is 
by auscultation. 

Most valvular murmurs are due to a change at the valvular 
orifice ; either a narrowing or stenosis, or an insufficiency with 
an inability to close the aperture, permitting regurgitation. 
The possible valvular murmurs in the heart (exclusive of 



THE HEART— VALVULAR DISEASES'. 391 

congenital effects) are caused by obstruction or regurgitation of 
mitral, tricuspid, aortic and pulmonary valves. Thus we may 
have two murmurs to each valve, or eight in all. Some of them 
are so rare that the general practitioner is likely to overlook 
them. If the heart-beats are very rapid, we may not be able 
to hear the murmurs as distinct sounds. They have all a com- 
mon quality, they are all blozving ; yet the sound itself may 
present all variations in the musical scale. The various names 
given to these sounds as sawing, cooing, etc., have but little 
practical value, as they teach us nothing as to the real source 
of the sound. 

These murmurs are not always heard with equal distinct- 
ness ; change of position may cause them to disappear or to 
become very faint. Exercise or undue .pressure of the stothe- 
scope will cause abnormal sounds to become louder. A murmur 
may be absent when the child is in absolute rest. It is very 
dif^cult to decide whether the murmur occurs during the 
systole or diastole. It is asserted that a sound which occurs 
synchronously with the apex-beat is systolic, no matter what 
its characteristics are. 

Having discovered the existence of a murmur in the heart 
we must next definitely locate its seat and character — whether 
it is an obstruction or a regurgitation. The fact that a sound 
has its maximum intensity near the seat of production, the 
closer we approach this seat the louder will the murmur become. 
The cut (page 392) from DaCosta shows us where the various 
valves are located, and it will aid in identifying the locality of 
the murmur. 

The scope of this work will not permit complete directions 
for auscultation in the various valvular diseases of the heart. 
Reference must be had to special works on diseases of the 
heart. (Keating & Edwards ; Hale ; Clapp on ''Auscultation 
and Percussion.") 

''After we have found a mitral stenosis, or insufficiency, our 
diagnosis is not complete until we have recognized the general 
and local changes consequent on their presence. In both, the 
chambers of the heart speedily become deranged, some by dila- 
tation, and others by hypertrophy, or by a combination of both. 
The left ventricle is usually found in a condition of hyper- 
trophy, as it receives the blood under high pressure from the 
pulmonary veins, and furthermore, it performs all its functions 
under high pressure also. The left auricle is always dilated, 
and the right ventricle hypertrophied. The early alteration in 
the heart cavities is not manifested by any disagreeable symp- 
toms in the patient until the compensation is deranged, and 
the cardiac equilibrium is interfered with. Then symptoms 



392 



THE DISEASES OF CHILDREN. 



such as palpitation, cougn, snortness of breath, and dropsy^ 
appear. 

" Tricuspid Disease. — Primary disease of the tricuspid valve 
is very unusual, except those cases of pre-natal origin. It less 
rarely occurs secondarily dependent on mitral disease which has- 
weakened the right heart. 



Jlortic or ogives 



'o^linoTvaTy artery vO'lv&fi 

3 




Diagram showing the points at which the separate valves may be listened to. 



" Stenosis is more rare than incompetency — so rare that it is 
hardly worth while to consider it. 

" Insufificiency causes many serious symptoms ; the first effect 
is to cause the right auricle to become dilated and hypertro- 
phied ; then the right ventricle, which soon encroaches upon the 
left heart. The portal system becomes congested, the liver 



THE HE A R T— VA L \ ' ULA R DISEA SES. 393 

enlarged, and hemorrhoids may arise. The urine becomes 
scanty and even suppressed. Edema and anasarca arise rather 
later than in other valvular diseases. 

'^Aortic insufficiency, arising primarily in infants, is among 
the uncommon clinical observations, excluding cases having 
congenital origin ; in older children it is not at all rare. The 
etiology of aortic insufficiency is much the same as we have al- 
ready considered in treating of the general subject of valvular 
disease. At this valve, however, we are more likely to have 
an insufficiency suddenly produced during sudden exertion from 
the rupture of a segment of the valve, occurring usually at the 
free border ; sometimes, however, at the insertion of a leaflet. 
It is difficult to believe that a healthy valve would rupture un- 
der these circumstances, and we must admit the existence of a 
previous valvular disease, which has weakened its structure. 

^^Symptoms and Physical Signs. — Of all the cardiac diseases, 
this is certainly the most easily recognized, both on account of 
its characteristic general symptoms and the acuteness with 
which the physical signs are defined. Corrigan first recognized 
this fact by describing the ' visible pulse,' so marked in this 
disease. The pulse is sudden and bounding, giving an impres- 
sion of seeming strength ; but it is elevated suddenly, and falls 
immediately. In the words of Corrigan, 'The arterial trunks 
of the head, neck, and upper limbs at once attract the eye by 
their peculiar pulsations ; at each diastole the subclavian, car- 
otid, temporal, humeral, and sometimes even the palmar arteries 
are projected forcibly from their bed and bound under the skin.' 
In order to better observe these points, we are in the habit of 
having the patient strip one arm, and preferably one side of the 
chest, separating the arm from the body, semi-flexing and supi- 
nating the forearm; the observer, at a glance, will be able to 
note the entire course of the arteries under consideration. Cor- 
rigan's original explanation, which has stood the test of years, 
cannot be improved upon: 'When the semi-lunar valves are 
healthy, they are closed by the pressure of blood immediately 
after each ventricular contraction. When the occlusion is com- 
plete, the blood propelled from the ventricle is retained in the 
aorta, and the large vessels remain distended. These vessels 
then maintain almost the same caliber in systole as in diastole. 
But when the valves no longer close the aortic orifice, a certain 
amount of blood contained in them is allowed to escape; they 
become flaccid after each ventricular contraction, and their 
diameter diminishes. At this moment a fresh contraction of 
the ventricle rapidly forces into the vessels a quantity of blood, 
which dilates them forcibly and suddenly. The arterial dias- 
tole is then marked by such a sudden increase in the caliber of 



394 THE DISEASES OF CHILDREN. 

the vessel that it produces a visible pulsation, constituting one 
of the signs of the disease.' The murmur is heard at the sec- 
ond right costal cartilage, ' the aortic cartilage ; ' it is heard as 
high as the upper border of the second intercostal space, also 
slightly to the right of the sternum, and descending downwards 
throughout the extent of the bone, inclining a little to the left 
as the ensiform cartilage is approached. Aortic insufificiency 
is accompanied by a murmur, which is diastolic in time, replac- 
ing the click of the semi-lunar valves and commencing with 
cardiac diastole, consequently occupying the greater portion of 
the period of silence ; it terminates with the diastole, or bet- 
ter — the murmur is cut short by the next systole. The sys- 
tole will be found to be shorter than normal, with a rapid 
subsidence. As the heart becomes hypertrophied, the mur- 
mur becomes more distinct and presents greater areas of trans- 
mission. 

"The general symptoms in young patients are apt to be 
latent for a long time, and the sole manifestations are the physi- 
cal signs. Later, hypertrophy of the left ventricle arises and 
the apex becomes lower than normal, producing an epigastric 
impulse, and displacing the left lobe of the liver downwards. 
As the case advances, the cardiac chambers become dilated ; it 
is then that we note an increase in the vertical diameter of the 
heart ; the tricuspid may become insufficient by a process of 
simple dilatation of the orifice. 

"The patient, if perfectly quiet, will be in comparative com- 
fort, but the slightest exertion will produce palpitation and 
distress, with a feeling of anxiety and oppression. Dyspnea 
becomes an exacting symptom, which muscular exercise or 
mental worry will increase to apnea ; it is the duty of the physi- 
cian in these cases to warn the parents or guardian of the neces- 
sity of correcting the child in a mild manner, and to especially 
caution them against the danger of violent whipping or seclud- 
ing the child in a lonely or dark room. Parents should see 
that these children are not unduly excited by their nurses 
reciting ' ghost stories,' or tales of reckless daring, culled from 
the unfortunately prevalent poor literature of the day. Among 
the most alarming cases that we have been called upon to treat 
have been examples of 'night horror' in young children with 
valvular diseases, whom a nurse or elder brother or sister has 
conned to sleep by some story gleaned from the cheap weekly 
papers scattered so broadcast throughout the country. 

" Occasional attacks of angina pectoris may arise, alarming 
the patient greatly, and introducing a new and serious element 
in the prognosis. The natural course of the disease in the 
young is slow ; when dilated hypertrophy arises, we then note 



THE HEART— VALVULAR DISEASES. ;59r> 

the symptoms of venous tension, congestion of the portal and 
pulmonary veins, with edema of the extremities.""^ 

Trcatjnent. — The treatment of valvular disease of the heart, 
especially in children, is not altogether medicinal. Without 
proper hygienic measures, drugs can do but little to assist the 
heart to overcome the lesions of its valves. Aided by a regu- 
lated life of the patient, the vis vicdicatrix 7iaturce must do all 
the rest. The cure, or a condition approaching it, is brought 
about by a process which is called compensation. It would be 
in vain for me to attempt to describe this process in my own 
words as clearly as it is described by Bramwell in his great work 
on the '' Heart and its Diseases," and I shall therefore take the 
liberty of quoting from that author. He says: 

" It might be supposed that every structural alteration which 
produces either stenosis or incompetence of a valvular orifice, 
is necessarily attended by symptoms due to disturbance of the 
circulation ; and such, in truth, would be the case, if it were 
not for the fact, that nature adapts herself to the altered con- 
dition of things ; and that certain secondary changes are grad- 
ually established, by virtue of which the bad effects of derange- 
ment of the circulation are resisted, and by means of which the 
normal balance, so to speak, of the circulation is maintained 
or reestablished. There is, in short, in almost all cases of 
valvular defect, a natural effort to compensate the lesion, the 
importance of which, in a practical point of view, it is impossible 
to overestimate. 

" The compensatory changes consist of alterations in the 
heart, the object of which is to restore and maintain the balance 
of the circulation, and to resist the injurious effects of the le- 
sions on the heart itself, and of certain changes in the peripheral 
tissues, by means of which the injurious effects of backward 
pressure and venous stagnation are, to some extent, prevented." 

The exact nature of these compensatory changes, which de- 
pend upon (i) the valve which is affected, and (2) the manner 
in which it is affected {i. r., whether stenosis or incompetence is 
the chief lesion), will be more appropriately considered when I 
come to treat of the individual valvular lesions in detail ; but, 
speaking broadly, I may say that in all lesions compensation is 
chiefly effected by hypertrophy of the walls of the cardiac cav- 
ity or cavities, which are situated behind the affected orifice. 
Alterations in the frequency of the cardiac contractions also 
exert an important compensatory influence, more especially, as 
we shall afterwards see, in the case of aortic lesions. When, for 
instance, the aortic orifice is contracted, the muscular wall of 



Keating and Edwards. 



396 THE DISEASES OF CHILDREN. 

the left ventricle becomes thicker, and the '^ driving " power of 
the left heart being materially increased, a larger quantity of 
blood is propelled in a given time through the narrowed orifice 
than could possibly have been the case in the normal (unhyper- 
trophied) condition. So again, stenosis of the mitral valve is 
followed by hypertrophy of the left auricle, but in this case the 
normal function of the auricle being passive rather than active, 
and the resisting power of its w^alls against the blood pressure 
depending not only upon muscular tissue, but also upon the 
connective tissue layers of the endocardium, the hypertrophy 
consists not only of an increase of the muscular wall of the au- 
ricle, but also of thickening of its elastic tissue lining. By these 
means its resisting power is materially strengthened, at the 
same time as its propelling power is increased. The reader 
must not suppose from this statement that all fibroid changes 
in the cardiac walls add to the resisting power of the organ. 
When the muscular tissue of the organ is replaced by fibrous 
tissue, as it is in fibroid degeneration, both the " driving " and 
resisting power of the organ are diminished. It is only when 
the muscular wall remains healthy, or is hypertrophied, that an 
increase of the fibrous tissue in the endocardium can possibly add 
to its resisting power. This increase of the connective tissue 
coat of the auricle is (in proportion to the amount of muscular 
hypertrophy) still more marked in mitral incompetence, in 
which condition, as we have previously seen, increased resist- 
ance is necessary to counteract the dilating force of the regur- 
gitant current, but in which there is no obstruction to the pas- 
sage of the blood from the auricle to the ventricle. So, again, 
in aortic regurgitation, the forcible passage of an abnormally 
large quantity of blood into the cavity of the left ventricle dur- 
ing its diastole (from the aorta through the incompetent valve, 
and from the left auricle through the mitral orifice), produces 
over-stimulation of the muscular fiber, in consequence of which 
hypertrophy of the left ventricle is produced, as we have al- 
ready seen, by the too forcible distension of the cavity while 
its walls are flaccid and relaxed. 

The hypertrophy, then, which follows and accompanies 
valvular lesions, is eminently beneficial, though it is not in all 
cases an unmixed good ; and I cannot insist too strongly upon 
the immense importance of this doctrine of compensation. 
The symptoms, as we shall afterwards see, are trivial, or alto- 
gether absent, so long as the compensatory changes are suffi- 
cient to balance the bad effects of the lesion ; the prognosis is 
very largely based upon the amount of compensation and capa- 
bilities of repair which are present, while the treatment is in 
great part directed to promoting and maintaining the hypertro- 



THE HEART— VALVULAR DISEASES. 397 

phy and other secondary changes, by means of which the 
balance of the circulation is restored and maintained in a com- 
paratively normal condition. 

The amount of compensation which is possible in any given 
case, depends chiefly upon the following circumstances : 

I . TJie suddenness, extent and character of the lesion. 

"A very extensive lesion, which occurs suddenly — rupture of 
the heart, for instance — may, of course, destroy life so rapidly 
that compensatory changes cannot possibly occur. 

** Then, again, a severe (but not immediately fatal) lesion, 
which occurs suddenly, is with difficulty compensated. Ruptures 
and ulcerations of valves are examples. 

" In other cases, on the contrary, in which the progress of 
the lesion is slow and gradual, compensation is easily estab- 
lished, and is very complete. In many chronic valvular lesions, 
for example, compensatory changes advance pari passu with 
the morbid process, and for a time, at least, the balance of the 
circulation is so satisfactorily maintained, that the patient 
(provided that he lives a quiet and tranquil life, and does not 
suddenly add to the difficulties of the circulation) may be 
unaware of the existence of any cardiac defect. 

"2. TJic reparative powers of the paticfit, and especially the 
capabilities of compensation existing in the heart itself. 

" 3. The resisting power of the tissues, which in its turn de- 
pends upon the soundness and vitality of the individual organs, 
and especially upon the vaso-motor nerve tone, and the vitality 
of the whole organism. 

" In young persons, where the tissues are healthy, and in 
persons of good nerve tone and tranquil disposition, compensa- 
tion is satisfactorily, and, for a time, at least, effectually estab- 
lished. Vice versa, in old people and in persons whose tissues 
are unsound or degenerating, more especially in those in whom 
the nerve tone is bad, compensation is, from the first, imper- 
fect, and the injurious effects of the lesion are speedily mani- 
fested in the form of symptoms. 

" The condition of the tissues, then, as a whole, and the 
reparative power and vitality of the patient are facts which the 
practical physician must ever keep prominently in view. Indeed, 
we lay it down as an axiom, that in looking at cardiac cases, 
whether from a pathological or a clinical point of view, and 
more especially in considering the prognosis and treatment, it 
is quite as important (I might even say that in some it is more 
important) to look at the condition of the system as a whole, 
as it is to regard the condition of the heart in particular. He 
is, in fact, a poor physician who concentrates his attention upon 
the tissue or organ which is primarily affected ; and this state- 



398 THE DISEASES OF CHILDREN. 

ment holds good, even should he succeed in arriving at an ac- 
curate estimate of the cardiac or other local lesion ; while the 
best physician is he who accurately gauges the nature and 
extent of the local lesion, and at the same time takes a broad 
and comprehensive all-around view of the case." 

I cordially subscribe to the excellent advice given by Bram- 
well in his closing paragraph. If we have a patient — a child or 
an infant — in whom we have discovered a valvular defect, the 
first advice to give to the parents or nurse, is to see that the 
child is kept in a condition of mental and bodily quiet until 
compensation has fairly set in and the muscular tissue of the 
heart has gathered strength to overcome the resistance to which 
it is subjected. 

I do not mean that ordinary exercise, in well-ventilated 
rooms or in the open air, should be forbidden, but that no un- 
usual exertion should be allowed. With children this rule is 
very hard to carry out, for it is difificult to restrain their exuber- 
ant animal spirits. It requires that the watchful eye of an 
attendant should always be upon them. 

The diet should be plain and nourishing; sweet-meats and 
high seasoned dishes must be withheld, for it is very necessary 
that the stomach and intestines should be kept in a healthy 
condition, in order that food should be properly digested and 
assimilated. I do not believe that a child with valvular disease 
of the heart should be allowed to go to a public school. If 
sent to a private school, its studies should be carefully selected^ 
for any cramming or overstudy will bring disaster. 

In some respects the kindergarten is objectionable, because 
the physical exercises in such schools are often severe and ex- 
citing. Dancing should be absolutely prohibited until some 
competent physician decides that compensation has so far 
advanced that it is permissible. Music or other exciting amuse- 
ments act upon the heart injuriously. Mental or emotional ex- 
citement is as bad for a weak heart as gymnastics or undue 
physical exertion. 

Compensation cannot take place without good blood to feed 
the tissues of the heart ; the blood must be enriched by tissue- 
making food, and if there is any anemia, ferrum, arsenic, china, 
calcarea, nux vomica and phosphoric acid should be given. A 
residence in pure air and the use of mild ferruginous waters, are 
of the greatest value. 

It is possible that we may assist in the resolution of swollen 
valves by the use of the iodides of lime, arsenic, baryta, aurum, 
or iron. Of these the iodide of arsenic is the most valuable. 
I do not advise stimulating the heart muscle, but we can aid com- 
pensation by giving the cardiac tonics in restorative doses. We 



THE HEART— VALVULAR DISEASES. 399 

should administer just enough to aid nature in her efforts, care- 
fully avoiding pathogenetic effects. Small doses of digitalis, 
cactus, strophanthus, adonis, convallaria, coronilla, spartein, 
caffein, nux vomica, ignatia, etc., can be given a long time 
without causing any but good results. We can judge of their 
good effects by the character of the pulse and the action of the 
heart. We should change the remedy from time to time, as its 
effects seem to wear off. When improvement seems at a stand- 
still under one medicine, another will take up the work, and 
improvement will begin anew. 

While the patient is under the influence of physiological 
cardiac tonics, all influences which tend to weaken the heart, 
or throw more work upon it than it should bear, must be 
avoided. Excesses in eating and drinking are injurious, for 
when the stomach is overloaded, the heart is also overloaded 
with blood. This, with the pressure of a distended stomach 
and abdomen, fearfully taxes the strength of a weak heart and 
prevents compensation. The same occurs when the skin is not 
in good condition. It should be kept warm by flannel under- 
wear day and night, for if the skin is cold the capillaries are 
contracted and an undue quantity of blood is backed up against 
the heart. I must protest imperatively against the practice of 
frequent cold baths in children with heart disease. A rapid 
hot sponge bath is all that should be given. Tea should not 
be allowed children with valvular disease. Coffee in modera- 
tion is much less injurious. Tobacco should not be allowed. 
Boys affected with any form of heart trouble should never 
smoke cigarettes. The patients with aortic incompetency 
while asleep should lie flat in bed on the back, for in that 
position they lower the height of the distending column of 
blood, and thus relieve both the cardiac circulation and the 
tendency to pulmonary congestion. A change of climate is 
often necessary to favor compensation. High altitudes are 
injurious ; never send such patients to Colorado or California. 
Low altitudes where the temperature is equitable and warm, 
dry or moist, are best. Such resorts are found in South 
Carolina, Georgia, Florida (particularly South Florida in win- 
ter), and some of the Gulf states. (See article on the " Geogra- 
phy of Heart Disease " in Hale's " Practice of Medicine.") 

The treatment of dropsy due to valvular disease must be 
met by cardiac tonics, selected not from the symptoms alone, 
but by the pathological condition of the heart and kidneys. 
Dropsy may be caused by lack of arterial tension in the renal 
circulation, in which case digitalis is the chief remedy ; next in 
value are caffein, strophanthus, adonis, convallaria, salicylate 
of theobromin ''diuretin), spartein, apocynum cannabinum, 



400 THE DISEASES OF CHILDREN. 

hellebore, veratrum album, etc. If the arterial tension is too 
high, owing to vaso-motor irritation, the remedies are aurum, 
glonoin, pilocarpin and iodide of sodium. We often find 
cases when it is advantageous, and even absolutely necessary, to 
alternate or combine these medicines with the digitalis group. 
In several cases I have removed cardiac dropsy with weak heart 
and arterial tension by giving digitalis and glonoin in alterna- 
tion (one drop of the Ic of glonoin with one to three drops of 
the tincture or Ix of digitalis), every four or six hours. 

In some cases it is absolutely necessary to run off the water 
through the bowels. Then we must resort to the bitartrate of 
potassa (lo to 20 grains every four hours), or elaterium, I to 5 
grains of the 2x ; or i drachm of epsom salts by the mouth 
or by enema, every 4 or 6 hours. While we are reducing the 
dropsy by these means, cardiac tonics must be administered 
to keep up the failing heart. 

Cardiac dyspnea is one of the most distressing symptoms 
of valvular disease. It is often so severe as to simulate angina 
pectoris. As a rule, cactus, digitalis, kalmia and other cardiac 
remedies will palliate or remove it ; but there are cases which 
require immediate relief, as the patient seems in danger of 
dissolution. Here glonoin acts with magical promptness and 
should always be at hand to be given by the attendant when 
required. 

In a paper on "Glonoin in Heart Disease," read before the 
British Homeopathic Society, by W. Spencer Cox, M.D., he 
reports several cases of extreme dyspnea with cyanosis, uncon- 
sciousness, and other alarming symptoms, promptly relieved 
by a single dose of one drop of the Ix dilution. Others were 
relieved by repeated doses of one drop of the Ic dilution. The 
relief was due to the power possessed by this drug of dilating 
the arterioles. 

In some cases of extreme arterial tension, with powerful ac- 
tion of the heart, veratrum viride will act favorably. 'Quebracho 
will greatly relieve continuous dyspnea, but does not relieve a 
paroxysm as quickly as glonoin. Given in doses of 5 to 10 
drops of the tincture, or 1-50 grain of its alkaloid (aspidosper- 
min), every 3 or 4 hours, it renders the sufferer from dyspnea 
more comfortable, enabling him to move about without loss of 
breath. But cases will occur when all the above means will 
fail to give relief, and we are then reluctantly obliged to resort 
to morphine, preferably by hypodermic injections. In very 
young children it is safer to give on the tongue, one or two 
grains of the 2x trituration every two or three hours. Cocain 
in the same doses has been used with benefit. If, with the 
extreme dyspnea and high arterial tension, the patient is 



THE HEART— ENDOCARDITIS. 401 

constipated, or the stools are pale and offensive, mercurius dulcis 
Ix every hour until purgation ensues, will surely give relief. 

ENDOCARDITIS. 

Endocarditis may occur in the fetus, and be found in the 
new-born infant. It is stated by Rauchfous, of St. Petersburg, 
that he saw three hundred cases of fetal endocarditis in several 
years. It is a little singular that so few cases have been re- 
ported in this country. I have seen and recognized but three 
in an obstetric practice of forty years, but I may have failed to 
recognize many more. 

Endocarditis before birth usually affects the right heart. 
Of Rauchfous' 300 cases, 192 were in that side. It has been 
accounted for on the theory that the increased blood pressure 
on the pulmonary leaflets was the cause. It is a fact that most 
■congenital cardiac diseases are located at the pulmonary orifice. 

The endocardial hyperplasia in these cases is generally a soft, 
red, pedunculated vegetation, arranged at or about the tricus- 
pid valves; sometimes on the mitral, and very rarely on the 
aorta or pulmonary artery. Arising during fetal life, they may, 
if the child survives, disappear; but they are apt to cause such 
structural changes as to give rise to cyanosis at birth. 

Endocarditis arising after birth, is a more common disease 
than is apprehended. Very few physicians, unless they have 
some special interest in this subject, ever examine the heart of 
an infant during a fever, or during the eruptive diseases of 
childhood. Yet a fever in childhood may be rheumatic, and 
endocarditis may occur during measles, scarlatina, variola or 
typhoid. It has been observed as a concomitant of erythema 
nodosum. It is a common accompaniment of chorea ; in fact, 
few cases of chorea exist without an endocardial complication. 
Rarely, it may be idiopathic, but it often exists as the first 
manifestation of inflammatory rheumatism. It often occurs in 
pleurisy, pneumonia, Bright's disease, diphtheria and pyemia. 

Rheumatism, however, is the most frequent cause, and sub- 
acute rheumatism in childhood is very often unrecognized. 
Keating and Edwards (" Diseases of the Heart in Children ") 
believe rheumatic endocarditis is more frequent in the child 
than in the adult. Out of twenty-one cases of rheumatism 
between the ages of fourteen and twenty, Vernay says only 
one escaped endocarditis. In forty-seven cases in children, 
D'Espine found only ten cases in which the sounds of the heart 
were perfectly normal. It is believed that the younger the 
patient, the greater the risk of the heart becoming affected. 

Symptoms and Diagnosis, — Unless the physician has unusual 
D. C— 26 



402 THE DISEASES OF CHILDREN. 

intuitive tact in the diagnosis of diseases of children, and is an 
adept in physical examination of the heart, he will often over- 
look an endocarditis. With the statement of the causes above 
mentioned before him, he ought to know when to be on the 
lookout for the disease — which is one-half the diagnosis. If 
the child is old enough, it will complain of a pain in the epigas- 
tric region ; they will put the hand on the ensiform cartilage if 
you ask them to locate the pain. Some will complain of pain 
in the left axillary region. If the aorta is involved, they will 
complain of sharp pain along its course, especially on move- 
ment. All have a disinclination to lie on the left side, and 
when put in that position are very restless and anxious. In 
very young children close attention is necessary to enable us 
to recognize symptoms of cardiac pain. When the myocardium 
is involved, palpitation is a prominent symptom, the precardial 
distress is great ; and a real " delirium cordis" — a tumultuous, 
violent palpitation — obtains as the disease advances, and some- 
times ends in sudden arrest in diastole. The temperature is 
variable, often ranging between 102° and 104° or from 100° to 
102°. 

The pulse is at first accelerated, later it is feeble and dicrotic 
and very difficult to count. Respiration is greatly affected, 
dyspnea appearing early, and is very distressing. Sudden and 
alarming dyspnea appearing in the course of almost any febrile 
disease of childhood is an indication of serious cardiac implica- 
tion. Cough is sometimes present and greatly aggravates the 
distress. Nausea and vomiting may be an early symptom and 
become violent, and towards the close may hasten dissolution 
by causing exhaustion and inanition. The patient may sink 
into an apparent typhoid state and death occur from heart fail- 
ure in diastole. 

Great irregularity and tumultuous action of the heart show 
increased severity of the disease, and the strokes of the apex 
against the chest become very marked. I have observed in 
some cases great distention of the veins of the neck with violent 
throbbing of the arteries. 

Physical Signs. — Percussion is of no value. Palpation may 
reveal irregularity of the heart's action, violent throbbing, and 
often a vibratory thrill. Palpation will give the exact location 
of the apex-beat, and tell us when the left ventricle is seriously 
involved, for then its location will be changed, or may disappear 
altogether in pericarditis with effusion. It will also promptly 
inform us when myocarditis occurs. Auscultation will give 
us better information. It will generally reveal a systolic bruit 
or murmur at the apex. In children this murmur is sometimes 
heard with startling distinctness. This sound may not be 



THE HEART— ENDOCARDITIS. 403 

confined to the apex, but may be transmitted in every direc- 
tion, even into the arteries. It is sometimes confounded with 
hemic murmur, or a pericardial bruit, but neither are so loud 
and distinct. 

An accentuation of the second pulmonary sound should be 
watched for, as that means a damming back of the blood cur- 
rent through the lungs, and pulmonary engorgement. Engorge- 
ment of the right heart follows such engorgement, and then 
we shall generally hear a tricuspid murmur. 

Prognosis. — While not necessarily fatal, our prognosis should 
be guarded. A complete recovery from a first attack is rare ; 
there will remain some damage which will invite future attacks, 
or if not watched will result in chronic valvular troubles. It is 
especially in septic diseases of children that serious results are 
most to be feared ; for the products of exudation or ulceration 
and emboli may be carried to the spleen, kidneys, or lungs, and 
cause engorgement, or to the brain, causing paralysis. 

Ulcerative endocarditis, or bacterial endocarditis, is the most 
dangerous form. It may be caused by minute abscesses in the 
valves beneath the endocardium, or septic exudation processes ; 
and are secondary to pyemia, or some infection poison in the 
blood. 

Treatment. — This will depend upon the cause. If rheumatic, 
the food should be modified so as to prevent an acid condition 
of the gastric tract and its resultant acidity of the blood. If 
an infant not at the breast, the milk should be sterilized and 
soda or some alkali added. Even in nursing children, some 
alkaline water like Vichy, or pure soft water impregnated with 
soda should be given to drink. Sugar should be prohibited, 
and all starchy food not malted — (subjected to a prolonged 
second baking). Frequent alkaline baths are to be recommended. 

It should be remembered that endocarditic rheumatism may 
occur previous to any other rheumatic manifestation. If a 
child has fever, and other causes are eliminated, always examine 
the heart. Several times in my early practice, by a neglect of 
this rule, I have found an endocarditis when it was too late. 
If we find the heart beating rapidly, forcibly, and the pulse 
small and hard, aconite is the remedy; but if the heart's beat 
and the pulse is bounding and very full, give veratrum viride. 
These two will control any fever in endocarditis from rheuma- 
tism, but they will not control the fever of septic and bacterial 
endocarditis. If the patient appears to have stitching pains, 
give bryonia, asclepias tuberosa, or arnica. If there are other 
rheumatic manifestations in the joints or muscles, salicylate of 
soda may be cautiously given. I have never found small doses, 
one-tenth to one grain every hour, cause any cardiac depres- 



404 THE DISEASES OF CHILDREN. 

sion ; but I have known larger doses to have that effect. The 
heart may tolerate them while the febrile excitement is at its 
height, but will not when the fever subsides. The salicylates 
should be stopped as soon as the heart becomes weak, irregular 
or intermittent. In this condition of the heart, cactus ix, digi- 
talis IX, and spartein 2x are the chief remedies — 5 to 10 drops 
of the former, and two grains of the latter, every three or four 
hours. Convallaria ought to be useful if there is much arterial 
throbbing and distension of the veins without fever ; but Keat- 
ing says he never saw any good results from its use. As it 
requires to be given in a low dilution, ix, to be of any benefit, 
and as the stomach might reject it, if irritable, I would advise 
the use of convallaramin in doses of i-ioo grain in sweetened 
water every three hours. If the urine is scanty, red, and very 
acid, the salicylate, benzoate, or bicarbonate of lithia should be 
given in the ix or 2x trituration — 5 gr. in a tablespoonful of 
vichy water every few hours. 

Much has been written about the danger of high tempera- 
ture in cardiac inflammations. It has been alleged that should 
it go above 104° Fahr., degeneration of tissue will result. I do 
not believe the temperature ever goes above 104°, except in ul- 
cerative endocarditis, in which any antipyretic, which forcibly 
lowers the temperature, does more harm than good. In such 
cases, I have found phenacetin ix to have a beneficial effect 
in rendering the patient more comfortable and preventing heat- 
accumulation. It will certainly calm the nervous agitation, and 
the suffering from extreme heat, better than aconite. If the 
patient sweats profusely, stop its use and give coffea ix, a drop 
or two every hour. There are other remedies which will be 
indicated during the course of the disease : namely, spigelia (a 
very important medicine), spongia, kalmia, apis, arsenicum, col- 
chicum, cimicifuga, naja, phosphorus, scutellarin, and veratrum 
album. In treating heart failure, with cold dusky face and 
extremities, and almost imperceptible pulse, glonoin will exert 
wonderful restorative power — better than alcohol or ammonia ; 
but it must be followed closely by, or alternated with, arsenicum, 
veratrum album, nux vomica, digitalis or cactus. A patient with 
endocarditis should be placed at perfect rest, not taken up or 
carried about, but soothed by the mother or nurse lying down 
by it. The room should be dimly lighted ; no excitement or 
visitors permitted, and no talking allowed by the bedside. If 
the child is very restless, some nervine, like scutellarin, passi- 
flora, coffea, or mono-bromide of camphor should be given. I 
have had good results in such condition from sulfonal and phe- 
nacetin, 2 to 10 grains of the ix in infants under three years, 
and the same quantity of the crude drug in older patients. 



THE HEART— PERICARDITIS. 405 

In the discussion on a paper read before the British Homeo- 
pathic Society (1893), by the late Dr. A. H. Buck, Dr. Byres 
Moir referred to his hospital experience among the poor children 
in London. He saw no reason why pericarditis, as well as en- 
docarditis, should not be congenital. The rheumatic symptoms 
of children with endocarditis were insignificant, consisting of a 
few aching pains ; but on listening to the heart a bruit would 
be heard. There was scarcely a day when he did not find two 
or three children, among his out-patients, with well-marked 
symptoms of endocarditis. He quoted Dr. V. Green, who 
stated that endo- and pericarditis are found often in very young 
children, and as the age increases the percentage becomes less. 
Dr. Moir said the form of pericarditis in children was very in- 
teresting. He had seen several cases where the pericardium 
was totally adherent. These cases were very often associated 
with chorea. He had found aconite acted well in the first stage, 
and bryonia or mercurius in the second stage of effusion. Dr. 
Blakely said he had frequently seen cases of congenital endo- 
carditis with hypertrophy. In these cases there were pericar- 
dial adhesions, apex-beat two and one-half inches outside the 
nipple line, and the action of the heart tumultuous and irregular 
to the last degree. The consensus of opinion relating to treat- 
ment was that aconite, bryonia, and mercurius were very useful 
remedies. Dr. Wyman Thomas had seen good results from 
salicylate of soda when aconite and bryonia failed. In several 
cases he gave ten grains every hour until the pain was relieved. 
Dr. Lough highly praised veratrum viride. Dr. Clifton said we 
should not neglect to study, in cases of rheumatism of the 
heart, kalmia, arnica, colchicum,guaiacum, lycopodium and san- 
guinaria. Dr. Edward Blake entertained no doubt of the pos- 
sibility of intra-uterine pericarditis. If anything interfered with 
the placental functions — and the after birth is the only fetal 
emunctory — toxines could be stayed in the fetal system, and any 
or many of the recognized septic invasions would take place. 

I (Hale) believe that if closer investigations were made into 
the causes of death in still-born children, or those who die 
shortly after birth, evidence would be found that the heart had 
been diseased in utero from some disease of the mother, 
namely : rheumatism, Bright's disease, gonorrhea, syphilis, or 
pyemia. Dr. Blake's suggestion was eminently practical. 

PERICARDITIS. 

Pericarditis is an inflammation of the pericardium or serous 
covering of the heart. This covering is composed of two 
layers, the visceral and parietal ; both may be inflamed. As 



406 THE DISEASES OF CHILDREN. 

a rule it becomes general ; only very rarely does it exist un- 
complicated with endocarditis and myocarditis. It is believed 
by many authorities that pericarditis is more common in the 
infant than in the adult. There is no doubt that it is frequently 
unrecognized, for it is a fact that post-mortem examinations re- 
veal its existence when it was not believed to exist during life. 

Rheumatism is without doubt the principal cause of pericar- 
ditis ; it has been observed in the newly-born infant. It may 
be caused by typhoid fever, scarlatina, measles, variola, the 
retrocession of eruptions, and Bright's disease. Some cerebral 
affections in children may coincide with pericarditis. Rillet and 
Barthez, in 300 cases of death by tuberculosis in children, 
observed ten cases of deposition of tubercles in the pericar- 
dium with acute inflammation of that tissue. 

Sibson reports that out of 326 cases of rheumatism, 63 had 
pericarditis, and 25 of these were from sixteen to twenty years 
of age. All the fatal cases were under twenty years of age. 

Symptoms. — Like endocarditis, pericarditis may be acute or 
chronic, primary or secondary. The symptoms are generally 
masked, latent, and ill-defined during the early stages. A 
symptomatic diagnosis in the child is beset with numerous dif- 
ficulties. The marked local pain observed in the adult is not so 
well defined in the child. It is not as able to point out the 
seat of the pain. It may be mistaken for pleurisy or pleuro- 
pneumonia of the left side. If there is a rheumatism or eruptive 
fever present, we shall be better able to make a diagnosis. The 
cough, respiration, pain on movement, and complaints of pain 
during these actions, may arouse our suspicions ; but we cannot 
be certain of the existence of pericardial inflammation without 
the aid of auscultation, and this will not greatly aid us until 
sufficient lymph has been exuded to roughen the surfaces of 
the pericardium, or an effusion has formed with its undoubted 
characteristic symptoms. Then a diagnosis can be surely made. 

Keating and Edwards (" Diseases of the Heart in Children ") 
give the following local physical signs : " We may then rely 
first upon the friction murmur and later upon the muffled 
heart-sounds, which may eventually almost entirely disappear, 
especially at the apex, the sounds at the base being heard until 
the fluid completely distends the pericardial sac ; the friction- 
sound or murmur will also linger until this condition pertains. 
This friction-sound is to and fro, that is, synchronous with the 
systole and the diastole, the former causing the inflamed and 
roughened surfaces to closely approximate, the latter to recede. 
We must bear in mind that the heart of a child is much nearer 
the auscultator's ear than that of an adult ; forgetting this point, 
auscultation is apt to be very confusing and misleading in the 



THE HEART— PERICARDITIS. 407 

young. The friction-sound, if it exists, will rapidly become 
more apparent, as in the child the membrane is formed with 
great rapidity. In pericarditis the bruit or murmur which is 
heard over the precordia may have two sources of origin : it 
may be due either to an intercurrent endocarditis or to peri- 
carditis alone and uncomplicated. A pericardial murmur in a 
child may closely simulate an endocardial bruit. The special 
and diagnostic characters of a pericardial friction murmur are 
as follows : 

'' It is usually basal, or directly over the body of the heart. 
The murmur is almost always double, or to and fro. 

" It is not transmitted into the vessels and circulation, but 
may be heard in a child over a much larger precordial area than 
in the adult. It is but rarely, however, heard over the posterior 
left thorax. The murmur, particularly in the young, will be 
altered by the position of the patient in being intensified as the 
subject leans forward, and rendered less audible during full 
inspiration or in the reclining posture. The effusion is apt to 
arise somewhat rapidly, and by inspection we may note a peri- 
cardial bulging, which, in children, is marked, and arises early. 
The ribs being flexible and the thorax small, the bulging be- 
comes more apparent. A rachitic deformity of the chest must 
be differentiated from the bulging due to an effusion. 

'' The distention of the pericardium will cause upward dis- 
placement of the apex-beat. This is coincident with the for- 
mation of the fluid, and is proportionate to its quantity. In 
cases where any amount of effusion has been poured out, the 
apex may be displaced one or more interspaces. The cardiac 
impulses, like that of an adult under similar conditions, will be 
materially diminished. The symptoms on palpation are about 
the same in both the child and the adult. 

The general symptoms are as follows : The disease may be 
ushered in by chill, fever, cerebral symptoms, such as delirium 
or choreic movements, followed by somnolence. The pulse at 
first may be regular, but as the cardiac muscle becomes weaker 
the circulation becomes irregular, and the radial pulsation feeble 
and intermittent. Later the pulse becomes small, irregular 
and intermittent ; there spiration is much embarrassed ; extreme 
dyspnea may arise, and even apnea appear, with actual as- 
phyxia." The temperature increases with the severity of the 
disease and in scarlatinal pericarditis I have known it to reach 
1 06° Fahr. 

Prognosis. — Recovery from pericarditis is common. It is 
not as fatal as endocarditis, but adhesions may form and cause 
dilatation of the cavities of the heart. This disease has been 
known to occur in the fetus and new-born. In children dying 



408 THE DISEASES OF CHILDREN. 

thirty-six hours after birth pericardial adhesions have been 
found. Pyemic pericarditis may follow inflammation of the 
umbilical cord. 

Treatment. — The treatment of pericarditis calls for many of 
the medicines used in endocarditis, especially aconite, veratrum 
viride, bryonia, asclepias tuberosa, apis and salicylate of soda. 
In addition, especially when effusion of lymph, or exudation 
has occurred, we shall find iodide of arsenic, iodide of potash, 
apocynum cannabinum, and iodine frequently indicated. To 
maintain the strength of the heart-muscle we are impera- 
tively obliged to resort to cactus, digitalis, caffein and spar- 
tein, and they must be used in physiological doses, namely, 
one or two drops of the tincture, or one grain of the ix tritura- 
tion every two or three hours. The same hygienic measures 
recommended in endocarditis should be adopted. 

The treatment of pericarditis with effusion combines medical 
and surgical measures. As soon as percussion and auscultation 
shows the presence of fluid in the pericardial sac, the kidneys 
should be stimulated to action, and at the same time the mus- 
cular structure of the heart should be toned up. This is best 
accomplished by the use of digitalis and apocynum canna- 
binum. Both have a similar action on the heart and kidneys. 
The dose of digitalis may be stated to be one drop for every 
two years of the child's age, namely, one drop every three hours 
for a child of one year and six drops for a child of twelve years. 
If the tincture of apocynum is used, the same dose is efficient. 
I prefer the decoction prepared after my formula in '^ New 
Remedies ;" of this, ten drops is equivalent to one drop of the 
tincture. Spartein is often very useful. The dose of this is 
one grain of the icevery two hours for an infant under two 
years of age, increasing one grain for each year of the child's 
age. If these medicines do not keep up the action of the 
heart, alternate them with nux vomica ix, or strychnia 3X. If 
the bowels are constipated I should not hesitate to give i-ioo 
grain of elaterin every four hours, or enough to cause watery 
motions. This will aid in relieving the cardiac dropsy. 

In no other disease is it so important to keep the patient 
absolutely quiet, even if we have to tie the child to the bed or 
cradle. Death has occurred suddenly from allowing the child 
to sit up in bed, or turn suddenly from side to side. Stimu- 
lants should be given ; the best are champagne, tokay and 
brandy. 

Paracentesis pericardii. — This has been resorted to when 
medicines will not cause absorption of the effusion, and when 
there is great danger of heart failure. The surgeon should not 
wait too long, as delay is apt to set up fatty degeneration of 



THE HEART— MYOCARDITIS. 409 

the muscular wall of the heart and dilatation of its cavities. 
** Use an aspirator with a vacuum jar, and a delicate double 
canula. The innermost portion may be either a solid needle 
or a needle-pointed tube, either of which are to be withdrawn, 
the former entirely, and the latter until its point is sheathed." 
— Keating. 

The point selected to aspirate is where there is the least 
danger of wounding the heart-muscle. " This is either in the 
left costo-ziphoid angle, pushing the trocar upward toward the 
heart ; or by inserting the trocar at the fifth interspace, about 
where the apex should normally be situated when it is not 
displaced." — Keati7ig. 

For further minute direction refer to Keating and Edwards, 
p. 88, also Table of Cases, p. 90. 

MYOCARDITIS. 

This disease is generally so complicated and associated w^ith 
endo- and pericarditis, and so difficult to diagnose during life, 
that it needs only brief mention. 

Dr. Blache classifies as follows the diseases with which myo- 
carditis may be associated : 

General illness. 

General diseases \ Grave fevers — variola. 

Cachexia. 



Local causes 



Alteration in circulation. 



f Diseases of pericardium. 

J Diseases of endocardium. 

I Diseases of vessels of heart. 

1^ Abscesses or tumors of heart. 

f Embolism. 

J Thrombosis. 

I Atheroma. 

1^ Edema. 



Symptoms. — The symptoms of myocarditis depend, of course, 
on its form and the extent to which the disease has progressed. 
When the lesion is small and limited, few, if any, symptoms 
exist at all by which a clinical diagnosis can be made. If, how- 
ever, the lesion is extensive, then we meet those symptoms 
which we all recognize as characteristic of heart-disease, as 
dyspnea, palpitation, dropsy, visceral derangement, or precor- 
dial discomfort ; nervous symptoms are peculiarly liable to arise 
early in these cases. 

Most cases of myocarditis pursue a long course ; should, 
however, an aneurism develop, the case will be more rapid. In 
other cases sudden death may occur from cardiac arrest. The 
most usual termination, is, however, by dropsies, pulmonary 
compHcations, or by exhaustion. 



410 THE DISEASES OF CHILDREN. 

Traumatism may cause myocarditis, and rapidly prove fatal. 
A case is recorded of a child aged twelve, who was kicked over 
the heart and died shortly afterwards with abscesses in the 
heart-muscle. 

" The diagnosis is indeed difificult, and in many cases quite 
impossible ; this is particularly true of the so-called cerebral 
form of myocarditis, which is especially noticeable during early 
life. Burnheim reports several cases in children. A child aged 
twelve, with febrile symptoms, delirium, agitation, and dilated 
pupils, died four days after admission. Child never had a pain 
in the chest, or heart-irregularity, or cardiac palpitation. At 
the post-mortem the heart was of a deep-red color, softened, and 
easily torn ; in the walls of both ventricles a number of abscesses 
were found, with quite a number beneath the visceral layer of 
the pericardium ; auricular muscle softened. Heart-clots were 
numerous. It is a clinical nicety to differentiate between cases 
of subacute or chronic myocarditis, and the heart that accom- 
panies emphysema, or that seen with renal disease, or, again, 
the heart that is altered by fatty degeneration." — Keating. 

The chief indication is to prevent heart failure. In cases of 
young children with delicate stomachs I would advise the use 
of the alkaloids of the cardiac remedies, for the small doses re- 
quired are much more easily administered and retained. Adon- 
din, convallarin, digitalin, spartein, strychnin, and cactina in 
doses of i-iooo of a grain (3x) are quite efficient if frequently 
repeated. I must here refer again to the necessity of absolute 
rest. Unless we can accomplish this, no medicine can relieve 
or cure our little patient. In cases of threatened heart failure 
from overexertion, give glonoin on the tongue. If abdominal 
distension interferes with the action of the heart, empty the 
intestines as quickly as possible. 

SYMPTOMATIC INDICATIONS FOR MEDICINES IN DISEASES 
OF THE HEART. 

[Only the most important are here mentioned. The well proven remedies 
are mostly omitted, as their symptoms are familiar to all]. 

Aconite. — Fever with great restlessness and anxiety ; high 
temperature ; hot, dry skin ; thirst ; pulse small, hard and quick ; 
stitches in the region of the heart with sudden crying out, 
moaning and tears ; rapid and painful respiration. Indicated 
in acute pericarditis, endocarditis and myocarditis. 

Arsenicum.— Y ^v^x of low type, with intense thirst ; some- 
times unquenchable, at others drinking only a little at a time ; 
temperature sometimes high, sometimes sub-normal ; uncontrol- 
lable restlessness and anxiety, great dyspnea — cannot lie down ; 



INDICATIONS FOR MEDICINES. 411 

feeble, irregular pulse. Indicated in ulcerative endocarditis; 
inflammation of the valves, during the progress of Bright's dis- 
ease, or typhoid fever ; dilatation of the heart with local or 
general edema. 

Adonis Vernalis. — Indicated in chronic valvular disease, or 
dilation withhypertrophy,with general anasarca, dyspnea, scanty 
urine, cardiac dyspnea, pulse feeble, irregular or intermittent. 
In such cases it acts as a cardiac tonic and diuretic when digi- 
talis has failed. Dose one to ten drops of the ix in infants 
repeated every two hours. In older patients one to five drops 
of the tincture. 

Apium Virus. — Sudden general edema, with suppression of 
urine occurring during pericarditis, scarlatina, or from a sudden 
cold after being overheated. Stinging pain in the region of the 
heart, dyspnea, very rapid breathing, with intense mental anx- 
iety. Always prescribe the trituration — 2x to 6x. 

Amyl Nitrite. — Sudden fainting; cardiac failure; with col- 
lapse, pulselessness, or feeble, irregular, almost imperceptible 
pulse ; cyanosis, cold face and extremities ; dusky lips and 
fingers, cold sweat. A few drops on a handkerchief placed be- 
fore the nose and mouth. As soon as a full pulse appears 
suspend the inhalation. In desperate cases administer it hypo- 
dermatically (one drop mixed with fifteen of water). 

Apocynum Cann. — This root contains a substance the phys- 
iological and therapeutic effect of which is said to resemble 
that of digitalis, except that it does not possess the cumulative 
power of the latter. 

Administered in the form of the fluid extract in doses of ten 
to fifteen drops, three times daily, Canadian hemp is said to 
render the pulse slower, and at the same time fuller and 
stronger. In cases of dilatation of the heart, it is stated, it rap- 
idly causes a decrease in the area of cardiac dullness ; and in 
patients affected with valvular lesions, it renders diuresis man- 
ifestly more active, does away with the edema, and determines 
the disappearance of palpitation and dyspnea. The remedy is 
usually well borne by the patients when administered in the 
stated doses ; the only disagreeable effect is occasionally a feel- 
ing of throbbing of the blood-vessels in the head. 

Dr. Glinsky reports its effect on himself ; being affected with 
hypertrophy of the left ventricle with dilatation of the heart, 
manifested in paroxysms and accompanied by a systolic mur- 
mur at the apex (symptom of mitral regurgitation), precordial 
angor and dyspnea, increased by the slightest m.ovement. 
Under the influence of the fluid extract of Canadian hemp, he 
found that all the morbid phenomena, both subjective and objec- 
tive, subsided in two days; the pulse, which beat at the rate of 



412 THE DISEASES OF CHILDREN. 

no per minute, fell to 80; and the dyspnea was so completely 
suppressed that even a lengthy walk did not cause the slightest 
feeling of oppression. 

In cases of valvular lesions of the heart, with symptoms of 
hyposystolia, in which strophanthus, adonis vernalis, and con- 
vallaria majalis had been administered without effect. Dr. G., 
in a few days, effected, by means of Canadian hemp, the disap- 
pearance of edema and dyspnea, as well as marked reduction 
of the area of cardiac dullness. 

It has been noticed, for many years, by myself and others, 
that when this drug was given for dropsy, the condition of the 
heart greatly improved. The fact that apocynin, its active 
principle, acts like digitalin, accounts for that result. Like digi- 
talis, the infusion or decoction often acts better than the tinc- 
ture. For children, five to ten drops of the ix every two hours, 
or double that quantity of the decoction, acts very happily. 

Glonoin. — Is applicable in cases when the emergency is not 
as urgent, although if given hypodermatically it acts almost 
immediately. The indications are the same as for amyl. Both 
dilate the arterioles and allow the blood to flow freely from the 
central portions of the body to the periphery. If given when 
the capillary circulation is arrested or stagnated, either from 
vaso-motor spasm or cardiac failure, the terminal vessels dilate 
and the congested heart is emptied of the blood in its cavities, 
which it was not strong enough to expel. No stimulant acts 
as quickly and beneficially in the cardiac or pulmonary diseases 
of children. Its timely use will ward off dangerous conditions 
approaching collapse. 

Aurum. — Is primarily indicated in acute congestion of the 
heart, great blood vessels, and brain ; also in endocarditis, when 
palpitation, suffocative anguish, and constriction of the chest 
are present, indicating diseases of the aortic valves. 

Cactus. — Dyspnea, anxiety, screaming with fear, sensation of 
an iron hand grasping the heart, with constriction of the whole 
chest. The pulse may be full, bounding, but soft, with some 
arterial congestion of the head ; or pulse small, weak, irregular, 
or intermitting. Primarily indicated in small doses in acute 
congestions, and cardiac inflammations in the 2x to 6x dilutions. 
Secondarily indicated in hypertrophy with dilatation, all the val- 
vular lesions when the heart is weak, with concomitant dropsy ; 
hemorrhages, and cardiac dyspnea — in doses of five to twenty 
drops of the ix or tincture, three or four times daily. 

These directions for dose are not theoretical, but deductions 
from my experience in the use of the drug. 

Convallaria. — Violent palpitation ; pulse large and empty ; 
throbbing and visible pulsation of the arteries (Corrigan's 



INDICA TIONS FOR MEDICINES. 413 

disease), or small, irregular, weak, and intermitting; distressing 
dyspnea ; pain about the heart radiating into the left arm, and 
down along its internal aspect into the fingers. Dropsy with 
general or local edema ; mental depression, melancholy or hys- 
terical symptoms. Suitable to infants after scarlatina, young 
girls at puberty who suffer from reflex cardiac neuroses ; pseu- 
do angina pectoris (in which the dose should be small, 2x to 4x). 
Valvular disease, especially aortic, or when the right heart is 
dilated ; in which the dose should be gtts i to v. of the tincture. 

Coffea and Caffein. — Coffea cruda is an invaluable remedy 
in neuroses of the heart in infants and young children and girls. 
The subjects in whom it is indicated are the offspring of neuro- 
tic parents who suffer from the effects of social dissipation or 
abuse of stimulants. The little patients are sleepless, irritable, 
affected unpleasantly by unusal noises or emotions. When 
sleepless or excited it will be observed that the hearts action is 
rapid, violent, and often irregular. In such cases the 3X or 6x 
dilution will act in the happiest manner. Caffein in the 6x or 
I2X will be equally suitable. 

Caffein causes secondarily — i. e., in toxic doses — paralysis of 
the heart in diastole, if its primary contraction in systole is not 
fatal. It is therefore valuable in physiological doses as a cardiac 
tonic when the heart is suddenly threatened with paralysis. 
The hearts of children, during peri- and endocarditis, are more 
prone to paralysis than those of adults. It follows well amyl and 
glonoin, after the immediate danger is passed. In such in- 
stances under the use of the ix or 2x in three to five grain doses 
every hour, the heart soon regains its force, and if dropsy is 
present, the kidneys soon resume their normal function. 

Car pain. — This is an alkaloid obtained from the leaves of 
the carica papaya, or " paw paw" tree of Florida and the trop- 
ics. It is from the fruit of this tree, which looks like a small 
melon, that the digests variously called papayotine, papaine and 
papoid are made. It is said that this digestive principle is 
found also in the leaves and bark, but the juice of the leaves 
cannot be inocuous if carpain is found in it, for it is a heart 
poison like digitalin. 

Dr. Von Orfele, who experimented extensively with car- 
pain, found it to act like the digitalis group of cardiac drugs. 
In doses of three-eighths grain per diem it caused similar dis- 
turbances in the rhythm, blood pressure and the pulse charac- 
teristic of digitalis. He also found that carpain was the 
only congener of digitalis that could be used hypodermatically 
without causing irritation and abscesses. The cardiac diseases 
for which it has been found most useful are aortic insufficiency 
and stenosis. In doses of one-tenth grain daily it effected reduc- 



414 THE DISEASES OF CHILDREN. 

tion of the frequency of the pulse, also alleviation of the dyspnea, 
and doubled the quantity of urine. This means doses of one or 
two grains, of the 2x trituration, repeated several times a day. 
Or, it is probable that the writer means that the one-tenth 
grain be given at a single dose, as the one-sixtieth grain of 
digitalin is now often given and allowed to act for a day or two. 

Coronillin, — The glucoside from coronilla scorpioides, an 
European plant, is equal in power to digitalin. Not sufficient 
experiments have been made on warm-blooded animals or prov- 
ings on men to enable us to decide just how it affects the 
heart. We only know from empirical data gained from its use 
in dropsy from cardiac disease, that it causes profuse diuresis, 
followed by great improvement in the condition of the heart. 
One authority who has experimented with it says it differs from 
digitalis in not causing as much contraction of the arterioles as 
digitalis. The dose is one or two grains of the second or third 
trituration. 

Digitalis. — As thoroughly as the best physicians of all 
schools are supposed to understand the action of digitalis, it is 
still often used inappropriately. It is too often the routine 
habit to give this drug when some valvular lesion is discovered, 
and there is at the same time a quick, irregular or intermit- 
tent action of the heart. But this is not an indication for its 
use, unless the pulse is soft and there is unmistakably ^l low 
tension in the arteries with venous stasis. Here it will always 
act favorably ; but if there is high arterial tension, or even 
normal tension, material doses will act unfavorably. 

If the primary symptoms of digitalis are present — viz,: rapid 
and strong, or quick and hard beating of the heart, with high 
tension pulse, digitalis is indicated only in infinitesimal doses, 
but I confess I have never seen good effects from its use in 
such cases ; aconite always gives me better results. But if the 
pulse is feeble, small, or large but soft, or *' empty," showing 
very low arterial tension, (which means a thin or weak heart) 
then digitalis in physiological doses, will nearly always act well. 
By physiological doses I mean for children, one to ten drops 
of the IX dilution or ix trituration. If the infusion is used the 
dose is ten to twenty drops, graduated according to the age of 
the patient. Rely more on the objective than the subjective 
symptoms. If the child is dropsical the attention to the state 
of arterial tension is of great importance. If the tension is 
above normal in the pulse, it is high in the kidneys, and then 
digitalis will not act as a diuretic in material doses, for it will 
increase the tension in the renal vessels, and sometimes sup- 
press the urine. Too high or too low tension in the renal 
arterioles will cause dropsy. Too high tension is rendered 



INDICATIONS FOR MEDICINES. 415 

normal by aconite, glonoin, aurum, veratrum viride and a few 
others. Too low tension is benefited by digitalis, caffein, 
strophanthus, cactus, adonis, spartein and nux vomica. 

ErythrophleiUy (casca) has been found to constrict the arte- 
rioles and cause a higher tension than digitalis, and may be used 
when digitalis is indicated, but is not well borne by the stom- 
ach even in small doses. The dose of casca for children need 
not exceed five to ten drops of the ix or 2x dilution repeated 
every two or three hours until its favorable effects appear. 

Oleander. — It sometimes occurs that during the treatment 
of valvular disease, or a weak, irritable heart in children, there 
will set in a lientery which rapidly reduces the strength of the 
patient. We have in such cases an admirable remedy in olean- 
der. Besides the evacuations of undigested food , the sudden 
movements of the bowels after taking food, which characterizes 
lientery , we find other important symptoms, viz.-. great pros- 
tration, stupor, dilated pupils, thick speech, anxiety about the 
heart with fear and trembling, pulse small, irregular, intermit- 
ting, often sinking to a thread, and suffocating, choking sensa- 
tions. Sometimes the heart beats slow, at other times rapid 
and violent. For these symptoms the 2x or 3x dilutions are 
appropriate. 

Spartein. — This drug which resembles convallaria and cactus, 
has one advantage which they do not possess. It acts more 
rapidly than any other cardiac sedative and tonic. Its quieting 
effect over a weak and irritable heart is often observed in less 
than an hour. It does not control irregularity of action, as well 
as abnormal rapidity. Hence it is the remedy for tachycardia 
in children. The other conditions in which it is useful are 
pulmonary emphysema with chronic myocarditis and irritable 
heart ; insufficiency of the aortic valves ; valvular disease with 
failing compensation ; weak, rapid action of the heart in 
Bright's disease, with deficient action of the kidneys, dropsy, 
ascites, etc. 

In threatened heart failure during scarlatina with endocar- 
ditis, one-tenth of a grain of spartein hypodermatically will act 
in fifteen minutes, and will thus sustain the temporary stimula- 
tion of amyl or glonoin. As a heart tonic and sedative use 
the 2x trituration in young infants, the ix in older children, 
repeating the dose every two hours. 

Spigelia. — The symptoms indicating this drug are too well 
known to be recorded here. When called for by those symp- 
toms it is of inestimable value in acute peri- and endocarditis ; 
the painful and stormy palpitations of all acute and chronic 
cardiac maladies ; but especially in violent cases of persistent 
tachycardia, exophthalmus, and chorea of the heart. 



416 THE DISEASES OF CHILDREN. 

Many functional disturbances of the heart are due to the re- 
flex irritation set up by worms in the stomach and intestines. 
Here spigelia has a happy effect in quieting such disturbances, 
but in order to prevent their recurrence the parasites should be 
expelled. 

Squilla. — At the time the original proving of squilla was 
madCf no method of testing its effects upon the heart was in 
use. But if a careful study of these provings be made, it will be 
seen how closely its chest and respiratory symptoms compare 
with the bronchial and pleuritic troubles which are so often 
present in mitral lesions. Owing to the imperfect supply of 
blood to the lungs in the mitral disease, the lungs and espe- 
cially the bronchial mucous membrane becomes congested this 
causes a profuse flow of mucus (bronchorrhea) or acute bron- 
chitis, also edema and venous stasis of the lungs, and even 
pleuritic effusion. The cough in such cases closely resembles 
the cough of squilla, namely loose, rattling, constantly harass- 
ing day and night, sometimes loose, then dry, spasmodic, dis- 
turbing sleep ; loose in the morning, dry in the evening. The 
expectoration is either glairy or bloody and is very difficult to 
raise, although a large quantity seems to be in the chest. The 
allopathic abuse of this drug is fearful. They give it to "loosen 
the cough." They do not know that the bronchorrhea which 
they cause is due to the congestion of the lungs and bronchial 
rriucous membrane, depending on cardiac weakness and irregu- 
lar action, and that many of the cases of so-called bronchitis 
and pneumonia in children are made worse by the toxic action 
of squilla. If the patients did not vomit up most of the drug 
the mortality would be greater. The pathogenetic action of 
squilla is not unlike convallaria — (all the liliaceae, in large 
doses, are more or less cardiac poisons). The primary effect of 
large doses of squilla is to cause increased force and more rapid 
contractions of the ventricles , the pulse is small and hard, wiry, 
then becomes irregular and very rapid, and finally ceases from 
tonic closure of the ventricles. During this time the pulmonary 
circulation is rendered imperfect, and there is present passive 
congestion. Hence the cough, mucus rales, bloody sputa, 
dyspnea, pleuritic pains, profuse urine, etc. It is my conviction 
that nearly all the symptoms of the chest and urinary organs 
caused by squilla are produced by the action of this drug on 
the heart, and, except in some cases of influenza, it is only in- 
dicated in chest affections when cardiac disorder is present. 
Many of the cases diagnosticated as bronchitis, pneumonia and 
pleurisy in children are probably due to acute endocarditis, 
pericarditis, or chronic valvular diseases, which we now know 
are very common in early life. In acute cases, presenting the 



INDICATIONS FOR MEDICINES. 417 

characteristic symptoms of squilla, it should be given in minute 
doses (third dilution), or the malady will be dangerously aggra- 
vated. 

Per contra, in cases of cough, dyspnea, bronchorrhea and 
pleuritic affections of a neglected or chronic nature, when the 
symptoms often assume the character of the secondary symp- 
toms of squilla, namely, constant hawking, loose or dry cough, 
great oppression of breathing, aggravated by movement and 
lying down, the face pale and cold, hands and feet cold and blue, 
heart's action feeble, irregular, palpitating, but always deficient 
in force, urine scanty, red, painful and often bloody, this rem- 
edy will be found promptly curative in larger but not patho- 
genetic doses. I have found the first dilution, in doses of five 
drops every hour or two, or the first trituration, in grain doses, 
act with the happiest curative effect. In dropsy from valvular 
disease it should not be used empirically, but always selected 
by the totality of its symptoms. 

Sterculia (Kola). — Kola, by the caffein and theobromin 
which it contains, is a tonic of the heart, whose pulsations it 
accelerates, while it increases its power and regulates its con- 
tractions. In the second phase of its action it becomes, like 
digitalis, a regulator to the pulse, whose energy it raises ; under 
its influence the pulsations become more ample and less nu- 
merous. As a result of its effect on the vascular tension, diu- 
resis augments, and this fact renders it valuable in affections of 
the heart with dropsy. It is a waste restrainer, diminishing 
the losses of the economy from the combustion of the azotized 
compounds, probably from special action on the nervous sys- 
tem. It is a powerful tonic by the principles which it contains, 
and its employment is indicated in anemias, in chronic affec- 
tions of debilitating character, and in convalescence from grave 
fevers. It favors digestion, probably by augmenting the secre- 
tion of gastric juice, and by acting on the unstriped muscles of 
the stomach, which it tonifies. Under its influence anorexia 
disappears, and the digestive functions become more regular. 

Kola increases the assimilation of food, and in cases of weak 
heart with chronic intestinal catarrh in children, will form an 
invaluable remedy. 

Lastly, it is an anti-diarrheic medicament of great value, and 
as such has rendered good service in chronic diarrhea, and in 
certain cases of sporadic cholera, although its action in these 
instances may not as yet be clearly explained. The mother- 
tincture may be used in doses of five to thirty drops. It can 
be given pleasantly in sweetened milk. Infants and children 
will take this without objection. 

Stigmata Maidis (Corn silk). — This apparently simple drug 
D. C— 27 



418 THE DISEASES OF CHILDREN. 

is of great value in some of the milder cases of chronic valvular 
disease with deficient compensation. The symptoms indicating 
it are : weak action of the heart, with irregular, intermittent 
pulse, deficient quantity of urine with frequent and urgent de- 
sire to urinate, only a small quantity being passed. Edema 
of the lower limbs and even general dropsy. Under the use of 
five to ten drops of the tincture every three hours, the urine 
will increase in quantity, and the irritability of the bladder de- 
crease, while the dropsy and weak, irregular action of the heart 
will disappear. 

Strophanthus. — This remedy has attained a good reputation 
as a substitute for digitalis. It is not open to many of the ob- 
jections against the latter. It does not contract the arteries to 
the same extent ; or derange the stomach, or show any of the 
so-called ''cumulative action." It is also efficient in smaller 
doses. This refers to its physiological action. Of its strict 
homeopathic uses we know but little, as we have no provings. 
There is one group of symptoms, however, which it has caused 
when given in too large doses. They are complete anorexia, dis- 
gust for all food, gagging and choking from regurgitation and 
vomiting of food soon after eating, with severe diarrhea. These 
symptoms sometimes occur during acute endocarditis, and then 
the 3x dilution will soon remove them. The following are the 
conditions it has removed : " In valvular weakness in the stage 
of compensation disturbance, tincture of strophanthus will re- 
tard, strengthen and regulate the cardiac action. The retarda- 
tion occurs first, while the regulating effect only takes place as 
a rule, after a few days. Dyspnea and edema are promptly 
relieved. But the favorable effects, in about one-half the cases, 
do not appear with the regularity and safety peculiar to digi- 
talis ; and in most cases in which strophanthus failed, digitalis 
was effective. Digitalis has, generally, a quicker and more 
thorough effect, especially in causing diuresis, while strophan- 
thus affects a disturbed respiration far more favorably. It is 
more difificult to indicate strophanthus than digitalis in cases of 
valvular weakness, so that it is almost impossible to say before- 
hand in what case strophanthus will be successful. 

In chronic degeneration of the cardiac muscle, with usually 
a small, frequent and irregular pulse, great difficulty in breath- 
ing and edemas, tincture of strophanthus may be relied upon. 

In acute and chronic nephritis the effect of strophanthus is 
not so marked as in the above mentioned affections. The dysp- 
nea often yields to its influence as in the other diseases, but 
the diuresis and edemas are not favorably affected by it. 

It cases of palpitation and apnea of nervous origin, strophan- 
thus often gives marked relief. 



IN Die A TIONS FOR MEDICINES. 419 

Edemas of cachectic character may be also favorably affected 
by it. For children, begin with doses of gtts. vij. of the ix in 
a teaspoonful of water or wine, and add gtts. ij. to each dose 
until the effect is obtained, though it is not advisable to give 
more than gtts. xx every three hours. 

The effect usually appears on the second or third day, and 
generally lasts a week or two weeks, though there is considera- 
ble variation. 

Zinc cyanide, — This drug is of great value in angina pectoris, 
and those reflex affections of the heart in children, which arise 
from irritation of the brain or stomach. The symptoms are 
sudden, violent pain in the region of the heart, with pale face, 
dusky lips, tossing about in anxiety, irregular, feeble pulse, 
vomiting, and sometimes stupor and convulsions. 



PART VI I I- 

DISORDERS OF THE URINARY TRACT 



CHAPTER I. 

THE URINE OF INFANCY AND CHILDHOOD. 

Quantity of Urine in 2^ Hours. — During the first ten days of 
life the infant passes, according to Cruse, from 130 c. c. to 417 
c. c. (4 to 14 ounces). The quantity increases rapidly during 
the first ten days, but more slowly during the next week. At 
the end of the first month the average is from about 200 c. c. to 
300 c. c. (6 to 10 fluidounces). During the first year, the aver- 
age is from 300 c. c. to 400 c. c. (10 to 13 fluidounces). 

During infancy the child passes about one fluidounce (30 c. c.) 
for each pound (half- kilogram) of weight : this figure applies 
especially to children between three and seven years of age. 

The following table shows the figures of different observers 
in regard to the quantity of urine in 24 hours : 



ULTZMANN. 

Infancy 300 c. c. (10 fl. oz.) 

Increasing 100 c. c. (3 fl. oz.) for 
each year until the 15th, when 
the normal quantity is 1500 c, c. 
(50 fl. oz.). 



SCHABANOWA. 

2 to 4 years. . .500 c. c. (16 fl. oz.) 
5 to 9 years. . 1000 c. c. (33 fl. oz.) 
[Q to 13 years.. 1500 c. c. (50 fl. oz.) 



HERZ. 

Boys of 8 700 c. c. (23 fl. oz.) 

Girls of 8 600 c. c. (20 fl. oz.) 

Boys of 10 750 c. c. (25 fl. oz.) 

Girls of 10 700 c. c. (23 fl. oz.) 

Boys of 12 1000 c. c. (33 fl. oz.) 

Girls of 12 800 c. c. (26 fl, oz.) 



CHARLES. 



3 to 5 (boys) 
3 to 5 (girls) 



750 c. c. (25 fl. oz.) 
700 c. c. (23 fl. oz.) 



In regard to the 24 hours' urine of the healthy new-born, 
Parrot and Robin think 150 to 300 c. c. (5 to 10 fl. oz.) the 
average from the 6th to the 30th day ; in other words, a new- 
born child passes four or five times more urine per kilogram of 
(420) 



THE URINE OF INFANCY. 421 

weight than an adult. Their observations on the quantity of 
morning urine voided were as follows : 

ist to 5th day, morning emission 5 to 10 c. c. 

5th to loth " " " 10 to 25 c, c. 

loth to 15th '• " " 15 to 30 c. c. 

15th to 30th " " '• 20 to 30 c. c. 

30th to 150th " " " 25 to 35 c. c. 

Clinical Note. — If then the urine diminishes notably it is 
because the child is sick or is fed in an insufficient manner. 

Collecting the Urine of Infants. — In order to collect the urine 
of young children, place a clean sponge over the genitals and 
fasten the diaper over it. The sponge, when saturated, is re- 
moved, squeezed out over a lipped dish, and the urine poured 
from the dish into a bottle or glass for measurement and 
examination. 

Color. — The normal urine of young children has little color, 
light yellow at most. If the first act of micturition be delayed 
twenty-four hours, the color of the urine will be dark, from 
concentration in the bladder. 

In two-thirds of the cases mentioned by Parrot and Robin,* 
the urine of the new-born was absolutely watery ; in the others 
very slightly tinged, of great refractive power, and of very 
light, straw-color, like that of old Chablis ; more rarely green 
reflections were noticed, especially when seen by transmitted 
light ; after standing some hours exposed to the air, the color 
deepened a little. During the first days of life, when the new- 
born child loses something of its initial weight, the urine is 
often more highly colored — rather yellow like that of the adult. 
The color may be further modified by the weight of the child 
and its alimentation; thus, it is darker with heavy children, and 
paler with those nursed by their mother than those who are 
brought up on the bottle or otherwise nursed. 

Temperature. — The temperature of the urine of the healthy 
new-born child varies only in a very small range, from 98.2° 
to 99.3°. 

Odor. — The urine of children has, in health, less odor than 
that of adults. After standing for a time, the odor somewhat 
suggests that of veal broth. Colorless urine is usually inodor- 
ous; that which has more color has a feeble, urinous odor, 
which boiling does not sensibly develop. 

Specific Gravity. — Contradictory statements are found in 
regard to the specific gravity. At birth the specific gravity is 
said by some to be about loio; it then sinks as low sometimes 

* G. E. Shipman's Translation, Chicago, 1878. 



422 THE DISEASES OF CHILDREN. 

as to I002, by the tenth day, gradually rising again. At the 
age of a month it may be as low as ICXD3. In general, during 
infancy, it varies from 1003 to 1006, though Schabanowa places 
the figures at ion between two and four, 1013 from five to 
nine, and 1012 from ten to thirteen. 

Cruse says that the specific gravity increases rapidly from 
the fifth to the tenth day, then diminishes; that the average 
specific gravity is from 1005 to loio. 

According to Parrot and Robin, with children from five to 
thirty days old, the mean density of the urine varies from 1003 to 
i(X)4. The product of the first urination is denser and attains 
the figures 1005 and 1006. From one to four months the den- 
sity is 1004 ^rid 1005. According to Quinquand, the density 
at birth is 1003; about the loth or 15th day, 1006. 

Reaction. — In the new-born the urine is normally neutral in 
reaction, only exceptionally being feebly acid. If the first 
micturition is delayed twenty-four hours, the urine may be 
acid from concentration in the bladder. 

Clinical Note. — Acid urine in the new-born is indicative of 
something wrong in the regimen as, for example, too long an 
interval between the nursings. 

Appearance. — For the first four or five days after birth the 
urine of children is rather turbid, owing to presence of 
epithelia, mucus, urates, and occasionally calcium oxalate. 
Later it becomes clear with the usual faint mucous cloud. 
The consistence is watery and the frothiness not permanent in 
health. 

The first act of micturition may be delayed twenty-four 
hours, in which case the urine will be turbid and concentrated 
by absorption in the bladder. But if the urine be passed soon 
after birth, it will be clear and pale. 

The urine of new-born children is light-colored, thin, limpid 
and of great mobility ; to this rule, according to Parrot and 
Robin, there are three exceptions. First, urines opalescent at 
the moment of expulsion, but which, after standing some hours, 
become limpid again, depositing at the bottom of the vessel 
very delicate and scanty flocks, made up of the epithelium of the 
urinary passages and of the vulva in case of female children ; 
second, urines light when passed and bleaching in from two to 
four hours, then becoming limpid again on deposit of the sus- 
pended matters causing the turbidity; these latter are bright 
crystals of uric acid formed at the moment when urine, neutral 
at first, has undergone acid fermentation. These two varieties 
of opalescence, observed especially during the first two or three 
days of life, are almost constant in children prematurely born. 
In the third case we find urines turbid when exposed to the 



UREA. 



423 



air for twenty-four hours or more, from development of micro- 
organisms. 

Clmical Note. — In the great majority of cases, limpid, thin, 
colorless, inodorous urine of low specific gravity is found only 
among healthy new-born children. 

Urea. — The amount of urea in 24 hours is best reckoned in 
grains per pound of body-weight, or grams per kilogram. 
The new-born infant up to one month of age voids about one 
and three-quarters grains of urea for each pound of body-weight, 
or 0.23 gram per kilogram. The following tables show the 
figures of the different authorities: 



CAMERER. 

Children void 5 to 8)^ grains for 
each pound of weight (0.64 to 
1. 12 grams per kilogram). 


HAREEY. 

Boy of 18 months — 
6.2 grains per pound. 
0.4 grams per pound. 
124 to 186 grains in 24 hours. 
8 to 12 grams in 24 hours. 

Girl of 18 months — 
5.4 grains per pound. 
0.35 grams per pound. 
93 to 140 grains in 24 hours. 
6 to 9 grams in 24 hours. 


RALFE. 

4)'2 grains to the pound for a 

weight of 40 to 60 pounds. 
4 grains to the pound for a weight 

of 60 to 120 pounds. 
Child of five of 40 pounds, 180 

grains in 24 hours. 
Child of twelve of 80 pounds, 320 

grains in 24 hours. 


UHLE. 

3 to 6 years — 73^ grains per pound, 

I gram per kilogram. 
8 to II years — 6 grains per pound, 

0.8 grams per kilogram. 
13 to 16 years— 3 to 4^ grains per 

pound, 0.4 to 0.6 grams per 

kilogram. 


HAIG. 

Child 3 or 4 years old, 9 or 10 
grains per pound. 



The analyses of Parrot and Robin showed that urine con- 
tained, as a mean, 3.03 grams per liter of urea in children from 
a day to a month old, of an average weight of 3850 grams ; 
hence, it results that every liter of such urine contains, per 
kilogram of child's weight, 0.80 gram of urea. A new-born 
child, which in twenty -four hours passes 300 grams of urine 
will then void 0.96 gram of urea, or 0.25 gram per kilogram 
of weight. But the age, weight, and bodily temperature 
modify in a very marked degree the quantity of urea. A 
new-born child passes more urea per liter and per kilogram 
of its weight on the first day of its life than on the twentieth, 
when the estimation per kilogram of weight is based on the 
urea per liter: but if the estimation per kilogram of weight 



424 



THE DISEASES OF CHILDREN. 



is based on the urea per twenty-four hours, it will be found, 
according to Parrot and Robin, that inasmuch as the twenty-four 
hours urine increases with age, the twenty-four hours urea in- 
creases also, and the urea per kilogram of weight also increases. 
The tables quoted by Parrot and Robin are as follows : 



PER LITER. 



Age. 


Mean weight 
of child. 


Urea per 
liter of urine. 


Urea per 

kilogram 

of child's 

weight. 


Number of 
experiments. 


First day 


Grams. 
3725 
3331 
4II7 
3760 

3559 
3937 
3560 
4918 


Grams. 

7 05 

4:38 
2.10 
1.70 
2-39 
2.73 
2.98 


I 05 
0.55 

0.60 
0.76 
0.63 


3 

5 
3 

I 


Second day 


Third day 


Fourth day 


c;th to 9th day. 


Tenth day 


18 


nth to 30th day 

30th to 150th day 



PER 24 HOURS. 



Age. 



Quantity 

of urine in 24 

hours. 



Quantity 

of urea in 24 

hours. 



Urea per 
kilogram 
of child. 



First day 

Second day 

Third day 

Fourth day 

5th to 9th day. . . 

Tenth day 

nth to 30th day. 
30th to 150th day 



Grams. 

15 

30 

60 

100 

150 
209 
300 
350 



Grams. 
O. 10 
O. 14 
0.26 
0.21 
0.25 
0.47 
0.81 
I .04 



Grams. 
0.03 
0.04 
0.06 
0.05 
0.07 
O. 12 
0.23 
0.23 



The apparent contradiction as regards urea per kilogram 
of child's weight is readily explained by considering the fact 
that the urea is reckoned differently in the two tables — in the 
first one relatively or physiologically, and in the second abso- 
lutely or clinically. 

A heavy child is said to pass less urea per kilogram of 
body weight than one of less weight, but more per liter of urine. 

According to Parrot and Robin, the more easily a new-born 
child is chilled the more urea per liter does the urine contain. 

The quantity of urea is constantly diminished in the ne- 
phritis of children. It is also diminished in anemia and chlorosis. 



UREA. 425 

Chlorine. — Children above three years of age void, according 
to Charles, 4.5 to 5.3 grams of chlorin, corresponding to 
71-2 to 8 3-4 grams of chlorides (116 to 136 grains), in the 
twenty-four hours. 

According to Parrot and Robin, in children from three to 
thirty days old, the general mean of chlorides was 0.79 gram per 
liter, or 0.22 per kilogram of body-weight. The chlorides 
estimated per liter of urine increased progressively from birth 
to the thirtieth day. 

In the urine of the new-born Parrot and Robin, in fifteen cases, 
always found chlorides, but sometimes in such small proportion 
that to determine them exactly was impossible. 

Sulphuric Acid. — The urine of the new-born contains sul- 
phates, but, according to Parrot and Robin, in too slight propor- 
tions to allow determination of them by weight. Accurate 
analyses of the sulphates in the urine of children are difificult 
to obtain. The works thus far consulted by the writer throw 
little or no light on the subject, except that the substances 
have been found to be diminished in cases of nephritis in 
children. 

Phosphoric Acid. — In the first eight days after birth, children 
excrete 0.014 to 0.032 per cent, phosphoric acid as compared 
with 0.19 to 0.23 per cent, in the adult. In young infants, the 
amount of earthy phosphates is very small. The proportion is 
much less in growing children than in adults. 

According to Cruse, the phosphoric acid increases after the 
tenth day. 

Von Jaksch, differing from other observers, has found that 
in some, though not all, cases of lobar pneumonia among 
children, the quantity of phosphoric acid eliminated during the 
continuance of fever was increased, as compared with the non- 
febrile period. He also finds phosphoric acid diminished in the 
urine of children suffering from nephritis. 

According to Parrot and Robin, a new-born child passes per 
liter more phosphoric acid from the sixteenth to the thirtieth 
day than from the first to the fifteenth, and the maximal quan- 
tity which the urine may contain during that period in the 
case of health is 1.95 gram per liter or 0.47 gram per kilogram 
of body-weight. 

Uric Acid. — In the new-born the quantity of uric acid is pro- 
portionally greater than in the adult, forming 0.13 per cent, 
during the first week, then decreasing up to 0.04, an adult 
secreting about 0.03 to 0.05 percent. The ratio of urea to uric 
acic in the new-born, according to Mares, is about 1:13-14. 

Ranke claims that neither age nor sex have any effect on the 
excretion of uric acid. 



426 



THE DISEASES OF CHILDREN. 



Saundly says the urine of the new-born contains much uric 
acid. 

Haig affirms that, in a child of three or four years, uric acid 
per twenty-four hours may amount to as much as 0.27 to 0.30 
grains per pound of body-weight. 

Von Jaksch finds uric acid diminished in the urine of children 
suffering from nephritis. 

Creatinin. — Infants on pure milk diet excrete little or no 
creatinin. Grocco finds very small quantities in the urine of 
babes on an exclusive milk diet. Boys ten to twelve years old 
excrete a mean of 0.387 gram (6 grains) in the twenty-four 
hours. 

Meat diet considerably increases the creatinin even in young 
children. 

Indican. — According to Hochsinger, indican is absent from 
the urine of the new-born and at best is only found in traces 
during the entire period of infancy ; but is increased in gastro- 
enteritis and in cholera infantum. Excluding primary intes- 
tinal or general septic diseases, the presence of pathological 
quantities of indican is indicative of grave intestinal disturbance 
or grave general functional change, especially tuberculosis. 
Smith has found amorphous masses of indigo-blue in the urine 
of a child affected with digestive disturbance. At least once 
these amorphous masses were replaced by minute rhombic 
crystals of a blue color. 

Urobilin. — A deep-brown zone of color, seen when Heller's 
cold nitric acid test, for albumen, is applied, and growing 
lighter as it recedes from the acid, is noticed in some cases of 
cirrhosis of the liver, and is regarded as an unfavorable sign. 
The same reaction is said to occur in cancer, lead-poisoning, 
alcoholic poisoning, rheumatism, gout, pneumonia, angina, and 
intermittent fever. It is considered by Hayene, a proof of 
hepatic incompetency, due to a languid liver manufacturing 
urobilin instead of normal bile-pigments. 

Albumin. — Albumin may be found in the urine of children 
under the following circumstances: 



1. Without known cause, so-called 
" functional" albuminuria. 

2. In febrile states. 

3. Due to presence of pus, blood, 
or chyle in the urine or found ac- 
companying bile. 



4. From pressure on renal veins 
by tumors, etc. 

5. In nephritis. 

6. In convulsions, epilepsy, etc. 

7. In poisoning. 



I. FUNCTIONAL ALBUMINURIA. 



Functional albuminuria is more common in boys than in 
girls. The quantity of albumin may be very small or quite 



ALBUMIN. 427 

large — as high as half by bulk. It is usually absent in the 
morning and present after food or exercise. No casts can be 
found, even after most careful search. 

Albumin is found in the urine of infants before the urinary 
secretion has begun, and in that of weak and delicate children 
at puberty. 

In regard to the prevalence of this form of albuminuria in 
children, the following may be of interest : 

It was found in 38 out of 97 children examined by Capitan, 
in quantities varying from 0.007 to 0.02 gram per liter 
(0.0032 to 0.009 grain per ounce). Stewart found albumin in 
the urine of 17 out 100 healthy children. Stirling found albu- 
min in J J out of 369 healthy boys. Leroux found albuminuria in 
5 per cent, of 330 presumably healthy children. Fiirbringer found 
it in 11}^ per cent, of 61 children. Janeway frequently finds 
albumin in the urine of debilitated children. De la Celle found 
albuminuria in 'j^ to 80 per. cent, of presumably healthy chil- 
dren from six to fifteen years of age, in quantities from 5 to 9 
centigrams per liter. 

2. ALBUMINURIA IN FEBRILE STATES. 

Albuminuria of brief duration, and rarely of prognostic signif- 
icance, is quite commonly found in the urine of measles, diph- 
theria and scarlet fever. Binet found albuminuria in all of 2J 
cases of pneumonia and broncho-pneumonia in children ; Eckert 
found it very common in cases of typhus and typhoid fever, 
occurring in three-fourths of all children he examined, appear- 
ing most commonly in the first week, or even the first days of 
the affection, and lasting usually about one, or one and a half 
weeks, the quantity of albumin having close relation to the in- 
tensity of the attack. 

Sejournet found albuminuria in children from fault of diet, 
the result of abnormal intestinal fermentations, and due to con- 
gestion of the kidneys. Such albuminuria evinced to some 
degree an infectious nature. 

3. ALBUMIN IN THE URINE DUE TO PRESENCE OF PUS, 
BLOOD, OR CHYLE. 

Urine of children containing pus will show albumin when 
the tests are applied. Pus in the urine may be due to gonor- 
rhea, which may be found in female children as the result of 
rape or inoculation from parents ; leucorrhea, which sometimes 
occurs in girls as young as three ; cystitis (most commonly in 
children due to stone); pyelitis, suppurative nephritis, malig- 
nant disease, and tuberculosis. (See Pyuria.) 



428 THE DISEASES OF CHILDREN. 

Urine of children containing blood will contain albumin also. 
(See Hematuria and Hemoglobinuria.) 

When chyle is found in the urine, albumin also occurs. (See 
Chyle.) 

4. ALBUMIN IN THE URINE DUE TO PRESSURE ON 
RENAL VEINS. 

The tumors which by pressure on the renal veins cause 
albuminuria are, in the main, those of carcinomatous nature ; 
sarcoma of the kidney has been noticed in children, also fib- 
roma and rhabdomyoma. Tyson includes under this heading 
pressure from hydatid cysts. (See Cancer of the Kidney.) 

5. ALBUMINURIA IN NEPHRITIS. 

When albumin is found in the urine, together with casts and 
renal epithelium, the question is one which will be discussed 
under the head of nephritis, q. v. 

6. ALBUMINURIA IN EPILEPSY. 

Albumin has been found by Huppert in the urine after full- 
formed epileptic seizures for from three to four hours. Other 
observers have failed to find it ; Mabille, for instance, in 38 
cases, failed to find any either before, during, or after the seizure. 

7. ALBUMINURIA IN POISONING. 

Albuminuria is common in children who are taking arsenic 
in large doses, as in the treatment of chorea. 

Peptone. — Binet found peptone in the urine of 34 infant 
patients out of 248. It occurs most frequently in diphtheria 
and in acute and chronic nephritis. He does not regard the 
symptom as of much value as a diagnostic and prognostic 
factor. Peptonuria is said to occur in some cases of diabetes 
insipidus. 

Arslan, of Paris, as a result of experiments performed in the 
scarlatina wards of the Sick Children's Polyclinic, draws the 
following conclusions : 

1. No peptone is found in the urine in mild cases of simple 
scarlatina. 

2. The urine contains peptone in grave cases of the disease 
associated with complications — the occurrence of the latter 
being even frequently preceded by peptonuria. 



ALBUMINURIA IN POISONING. 429 

3. The presence of a considerable quantity of peptone in the 
urine is an unfavorable sign. 

4. The peptonuria is in no way influenced by the presence 
of albumin, the condition of the pulse, or the temperature. 

5. In grave cases of scarlet fever, and in those complicated 
with gastro-intestinal disturbances, indicanuria becomes super- 
added to peptonuria. 

Propeptone, — Propeptone, according to Heller, may occur in 
scarlet fever, not only with albumin, but even when no evi- 
dence of renal disease is apparent. He does not regard it as 
unfavorable from a prognostic standpoint. 

It may be well to remember that Von Koppen has noticed 
the existence of propeptone in the urine of the insane, espec- 
ially of acute maniacal and excited cases. 

Bile. — Bile may be found in the urine of children as in 
adults. 

It is chiefly in cases of icterus neonatorum that w^e see it. In 
severe cases of icterus neonatorum, the urine is high-colored 
from bile pigment and stains the linen. Malarial and mias- 
matic poisons and phosphorus poisoning are sometimes causes 
of the condition in older children. Disappearance of biliary^ 
coloring matter from the urine is the first sign of improvement, 
and will be seen sometimes considerably before the jaundiced 
hue of the skin is lost. When bile is present in urine, albu- 
min is also found in small amounts. 

Sugar. — According to Neumann, there is found in all chil- 
dren's urine small quantities of a substance which reduces the 
alkaline copper test-liquid. This substance is especiall}' notice- 
able in cases of severe nervous or digestive disorders. Sugar 
itself, how^ever, in appreciable quantities is, as a rule, significant 
of diabetes, if found permanently in the urine of children. (See 
Diabetes.) 

Acetone ajid Diacetic Acid. — Acetone is found in the urine of 
children under the following conditions : 

1. In very small quantities in healthy children. 

2. In febrile diseases of children, increasing with fever and 
diminishing with its decline. 

3. In sudden epileptiform convulsions it is enormously 
increased in quantity, but cannot be regarded as the cause of 
eclamptic seizures in general. 

4. In diabetes mellitus. 

Schrack finds acetone in the urine of children not infre- 
quently, especially in febrile affections and in acute gastro- 
intestinal derangements. It may, however, be absent even in 
high and continuous pyrexia. Diacetic acid he finds also quite 
frequently, and almost constantly in high and continued fever, 



430 THE DISEASES OF CHILDREN. 

and quite commonly in the acute infectious processes, even if 
there be but little attendant fever, as is also the case with 
acetone. 

Diacetic acid, according to Binet, occurs in the urine com- 
monly in febrile diseases of children, but it is not found uni- 
formly in all febrile conditions ; it presents no definite relations 
to the intensity of the fever, the dyspnoea, nor digestive dis- 
orders. It is especially frequent in scarlet fever, and in some 
doubtful cases its presence and degree may be regarded as of 
some diagnostic value. Binet found it, using the ferric chloride 
reaction, in lo cases out of 23 in pneumonia and broncho- 
pneumonia; in 16 out of 26 of measles; in 27 out of 34 of 
scarlatina ; in 4 out of 4 of erysipelas ; in only 1 1 out of 
31 in diphtheria ; in 2 out of 4 of typhoid ; in 2 out of 4 of 
tubercular meningitis; in 2 out of 15 of acute nephritis; in 
2 out of 13 of various suppurative diseases (i of bone tubercu- 
losis and I of sub-diaphragmatic abscess). 

Diacetemia is said by Von Jaksch to be much more frequent 
in children than in adults. The child feels weak, has a thickly- 
coated tongue, often slight conjunctival catarrh, sometimes 
vomiting, usually constipation, and very little or no fever. In 
two or three days all of these symptoms, together with the 
diaceturia, disappear. In other cases nervous symptoms are 
more marked. Von Jaksch believes that all of these, as well as 
a certain number of other convulsive attacks in children, are 
the result of anto-intoxication with diacetic acid. 

Chyle. — Chyle has been found by Prout in the urine of a male 
infant 18 months old. In older children it often disappears 
after rest in bed. The condition is most common in the tropics. 

In chyluria the urine is usually white and opaque, like milk ; 
on standing awhile it sets spontaneously into a trembling coag- 
ulum, which after a time redissolves and breaks into flaky clots. 

Myers, of Indiana, saw a case in which a child of eleven, 
female, had what was supposed to be sciataca for five years, 
until placing of a seton in the upper portion of the left thigh 
revealed presence of chyle in the leg. After a time the flow of 
chyle from the leg ceased and chylous urine appeared in large 
quantities. 

Organic Acids. — Lactic, formic, acetic, and hippuric acid are 
said to be present in some cases of leukemia, but absent in 
others hence are of little or no diagnostic import. 

Allantoin. — This substance is found in the urine of new-born 
children within the first eight days after birth. 

Pyrocatechin.' — This substance, called alkapton by Bodecker, 
has been found in abnormal quantity in the urine of a child. 
Urine containing it darkens on exposure to the air. 



URINART SEDIMENTS. 431 

Urinary Sediments. — The urine of children suffering from 
febrile attacks often contains a milky-white sediment, due to 
presence of sodium urate, which under the microscope exhibits 
irregular, opaque, globular, and lumpy masses, from which 
project spiny crystals. These spiny crystals, being precipitated 
within the urinary passages, irritate the mucous membrane of 
the bladder or urethra, and may even block up the canal of 
the latter ; they may also form a nucleus around which calcu- 
lous matter may hereafter aggregate, since urates form the 
chief part of the nucleus in the majority of urinary calculi. 
The great comparative frequency of vesical calculi in children 
is not improbably owing to the occurrence of this deposit in 
the numerous fugitive febrile attacks to which children are 
subject. 

This whitish sediment of urates is easily distinguished from 
phosphates, in that it is dissolved when heated in the urine 
containing it. It is not necessary to heat to boiling in order to 
dissolve it. 

The urate sediment is common in fevers. An abundant sedi- 
ment of urates may be found, for example, in scarlatina. 

They are also found in the urine of chorea, and entero-colitis. 
Some children seem specially liable to these sediments, and 
appearance of them is accompanied by frequent desire to uri- 
nate ; at the same time there is evidence of general disturbance, 
malaise, etc. Nux and calcarea will often be found useful in 
such cases. 

Uric acid often occurs in the sediment of children's urine. 
(See Lithemia.) Its appearance to the naked eye is that of 
red-pepper grains. 

In cases of flatulence, the urine may contain a whitish 
sediment of amorphous phosphates, readily soluble in nitric 
acid. 

The urine of the new-born sometimes contains deposits of 
calcium oxalate, recognized as small, colorless crystals of a 
square letter-envelope appearance, seen best with a power of 
400 to 500 diameters.* 

According to Parrot and Robin, the presence of crystals in 
the urine of the new-born is one of the rarest of occurrences, 
and one which should always lead us to suspect a pathological 
condition, except in the first days following birth, after the 
urine, on standing, has undergone acid fermentation. 

Xanthin. — Has been found in the urinary sediment of a ten- 
year-old child, who, three years before had had symptoms of 
renal coHc. The crystals are whetstone-shaped and soluble 



See " Practitioner's Guide to Urinary Analysis," Gross and Delbridge, Chicago. 



432 THE DISEASES OF CHILDREN. 

when the urine is heated. Xanthin calculi have been met with 
in children in several cases. (See Calculi.) 

Leucin and tyrosin may be found in the urine of children in 
cases of acute yellow atrophy, a very rare disease in children. 

Cystin. — Has been found in the sediment of children's urine, 
in some families occurring instead of uric acid. W. G. Smith, 
observed cystin in the urine of a boy of eight ; the urine had 
an odor suggesting orris and the sediment was green in color. 
Making six examinations, he found cystin once. The child 
seemed to suffer no harm from its presence, not even for years. 

Cystin has been found in a calculus removed from the bladder 
of a boy six and one-half years old. The urine prior to the 
operation was alkaline and contained much sodium chloride. 
Directly after the operation the urine became acid ; but eight 
weeks later the alkaline reaction recurred again and cystin was 
recognized in the sediment. Cystin was found by Toel in the 
urine of two girls, partly in solution and partly as a sediment. 

Fat in the Urine.— K case is recorded by Drecker in a female 
child of twenty-eight months. In the surface of the urine 
floated a layer of butter-like substance, which, on application of 
heat, appeared like ordinary fluid fat. The urine then became 
milky, and looked like thin milk-broth with fat floating on it. 
It had a peculiar aromatic odor, different from that developed 
ordinarily when urine is boiled. A drop on blotting paper 
made a greasy mark, not disappearing on drying. Heated with 
liquor potassae it saponified. It also gave other proofs of be- 
ing fat. It was present in 4.35 grams in every 100 C. C, or 
about 22 grains to the fluidounce. The child was dull, sleepy, 
very thirsty ; perspiration had unpleasant odor ; there was 
furred tongue and vomiting ; five or six times daily a white, 
pap-like stool, with dark streaks through it, occurred ; the face 
was swollen ; there was ascites ; there was tenderness over 
kidneys ; skin dry, cool, and on upper arm finely desquamatory. 
No cause for the condition of the urine could be given. She 
had been very ill four months previous with catarrhal symp- 
toms of lungs and stomach from which she had apparently 
recovered in three weeks. 

Epithelia. — The various epithelia may be found in the urine 
of children as in adults. It is only when the sediment is very 
abundant, pointing to an exaggerated desquamatory condition, 
that our attention is called to the condition. According to 
Parrot and Robin, mucus or hyaline cylinders are not found 
at all in the urine of the new-born in the state of health. Epi- 
thelia from the bladder, urethra, and vagina, together with 
more rarely, those from the tubes of Bellini, are found in the 
urine of the new-born. 



GENERAL SUMMARY. 433 

URINE OF THE NEW-BORN. 

General Summary. — Parrot and Robin draw the following 
conclusions : 

"I. The urine of the new-born child is colorless, inodorous, 
thin, of great refraction, clear and limpid, of a mean density of 
1003-1004. The quantity passed in twenty-four hours, from 
the 6th to the 30th day, varies from 100 to 300 c. c. 

"The morning emission is from 10 to 30 c. c. A new-born 
child urinates four times more than an adult for each kilo- 
gram of body-weight. 

''2. During the first two days the urine is more colored, more 
scanty, more dense, and sometimes opalescent. 

*' It presents the same characteristics with children whose 
alimentation is defective. The sex, the age and the tempera- 
ture do not exert any influence upon the physical characters. 

"3. It is not sedimentous, but, on standing, it lets fall a 
very small quantity of anatom.ical elements, to wit : cells of 
the bladder, of the urethra, of the vagina, and more rarely, 
in the first days of life, cells detached from the tubes of 
Bellini. 

" In circumstances, quite exceptional, the urine may give a 
very light deposit of uric acid crystals, or of oxalate of lime, or 
of urate of soda (the first day's urine — insufficient or vicious 
ahmentation, etc.) 

" Vegetable ferments appear to develop in it, more rapidly 
than in the urine of adults. 

'*4. The test paper shows an acid reaction. The acidity of 
the urine indicates, most usually, too long an interval between 
the nursings, and, in a certain number of cases, may indicate a 
pathological state. 

"5. It contains, per liter, 3.03 grams of urea and 0.80 gram per 
kilogram from a child weighing 3,850 grams. But in the twen- 
ty-four hours, the new-born child, from 11 to 30 days old, passes 
about 0.91 gram of urea and 0.23 gram per kilogram of its 
weight. 

"6. The age, the weight, and the temperature probably 
influence the quantity of urea ; hence the urine of two chil- 
dren, whose age, weight, and temperature differ, present un- 
equal quantities of urea; before explaining this difference by a 
pathological state, we must be sure that the excess of urea 
passes the limits which we have fixed for the variations due to 
these causes. 

"7. There exists a constant relation between the quantity 
of urea, the color, and the reaction of the urine ; so that the 
inspection of the urine and its reaction permit us to appre- 
D. C— 28 



434 THE DISEASES OF CHILDREN. 

ciate, clinically, the proportion of urine without reagent or 
analysis. 

''8. Traces of uric acid normally exist in the urine of new- 
born children, but their quantity cannot be determined. The 
urine of the first days contains more of this than subsequently. 

" 9. It does not contain extractive matters cHnically appreci- 
able, but it contains hippuric acid and allantoin. 

'' 10. In no circumstance does the normal urine of the new- 
born, or of the fetus, contain albumin. 

"II. Chlorides and phosphates are found in the urine, the 
quantities of which vary according to age and alimentation, 
also sulphates of lime, magnesia, potassa, and soda. 

** 12. It produces no reducing action upon the liquor of Bar- 
reswil (sugar test). 

'' 13. The new-born ingests, in twenty-four hours, and per 
kilogram of his weight, twice as much nitrogen as the adult ; he 
passes six times less by the urine, although he retains, at least, 
as much oxygen ; hence he burns less while absorbing more of 
the combustible and, at least, as much of the burner. 

'* This excess of assimilation over disassimilation, experiment- 
ally demonstrated, is, in relation with the daily increase of 
weight, an augmentation in which a portion of the oxygen 
absorbed must take part. 

** 14. The new-born child excretes less chlorides than the 
adult, only because he takes in a much less quantity. 

"15. The variations of urea, according to age, weight, and 
temperature, are easily explained by the modifications exerted 
upon the nutrition, by these influences. 

" 16. When the urine of a new-born child is modified, in one 
of its characteristics, beyond the limits which we have laid 
down, we may think, first, of an irregularity in the alimenta- 
tion, then of a morbid state. 

" 17. Circumstances exist where, according to the mode of 
grouping the alterations of the urine, we may determine the 
existence of a special pathological state, or of a particular 
symptom (edema of the new-born, diarrhea, etc.). 

" 18. In other cases, the study of the urine allows us to fore- 
see the near approach of particular accidents, such as edema, 
athrepsia, etc. In fact, a lesion of nutrition evidently precedes 
the appearance of external signs of these affections, and the 
child is already sick, even when no symptom outwardly reveals 
this state of suffering, the extent of which is shown by the 
alterations of the urine." 



CHAPTER II. 

THE URINE IN VARIOUS DISORDERS OF CHILDHOOD. 

Masturbation in Female Children. — Dr. Charles Heitzmann, 
of New York, recently demonstrated to me the diagnosis of 
masturbation in female children by means of microscopical ex- 
amination of the urine. The case was a child of nine years ; 
the urine contained, in addition to the large epithelia from the 
upper layers of the vagina, connective tissue shreds, epithelia 
from middle layers of the vagina, epidermal scales from the 
nymphse, fat granules of sebaceous origin (smegma) and 
Bartholinian epithelium. Heitzmann's diagnosis was intense 
vaginitis, vulvitis, and Bartholinitis due to rubbing. The 
child was watched by the parents and the diagnosis confirmed. 
Dr. Heitzmann tells me that arriving at a similar diagnosis in 
some five or six other cases, the children were watched and 
caught in the act in every case. The important point in the 
diagnosis is discovery of connective tissue shreds in the urine 
in female children not suffering from the other disorders in 
which connective tissue is regularly found. 

Tetanus. — In tetanus we find diminished quantity of urine, 
of high color. There is difficult micturition and occasionally 
the catheter is required. 

Fevers. — The twenty-four hours quantity is diminished and 
amorphous urates are deposited as the urine cools ; if there is 
temporary retention of urine then the hedgehog crystals of 
sodium acid urate are found ; during convalescence the sedi- 
ment will contain simple phosphates and sometimes uric acid 
or calcium oxalate. A trace of albumin may be temporarily 
found during the febrile attack. 

Typhoid Fever. — The features are as follows: There may be 
transient albuminuria, but casts are rarely found ; the bacillus 
typhosus, if found at all, only occurs, it is said, in the sediment 
of albuminous urine. Retention of urine may occur and the 
catheter need to be used occasionally ; if the catheter be not 
properly disinfected, urethritis, vesical catarrh, and even epi- 
didymitis may ensue. Polyuria in the course of tyhoid fever 
in children has been remarked. 

Spinal Paralysis. — In the spinal paralysis of children, mictu- 
rition is sometimes a little disturbed at the beginning of the 

(435) 



486 THE DISEASES OF CHILDREN. 

disease ; but in most cases this disturbance completely disappears 
later. 

Migraine. — In cases of persistent headache, look for constant 
or frequent appearance of urates, uric acid, and calcium oxalate ; 
the latter, if found, point to uricemic (lithemic) origin of the 
headache. (See Uricemia.) 

Whooping Cough. — Involuntary evacuations of urine some- 
times occur in whooping cough, following violent contraction 
of the abdominal muscles. 

Schiltema records a case of acute nephritis occurring after 
whooping cough in a child two years of age. Mircote declares 
that the kidneys are affected in whooping cough in about twelve 
per cent, of the cases, and believes that the renal affection is 
due to venous stasis, caused by obstruction of the vena cava 
through the violent paroxysms of coughing. 

Diphtheria. — In simple or follicular sore throat, albumin 
rarely, if ever, occurs in the urine, while in diphtheria a trace 
of albumin is very common. A greater or less degree of albu- 
minuria exists in most of the severe cases, usually when the 
disease is at its height, less often at a later period. A few 
casts may be found, but seldom much blood. 

Bouchut and Erupis have found albuminuria in 66 per cent, 
of their cases. See in 50 per cent, of his, Barbier in 75 per 
cent., Sanne in 224 cases out of 410, and J. Lewis Smith in 24 
out of 62 consecutive cases. 

It may occur as early as the first day, though rarely, and a 
large majority of the recorded instances have been between the 
first and eleventh days. The urine differs in appearance from 
that of scarlet fever, by being apparently normal to the naked 
eye. It is sometimes present even in mild attacks of diphtheria. 

As a rule, the albuminuria does not usually tend to a fatal 
result, but in severe cases, with other symptoms unfavorable, a 
large proportion of albumin, together with marked diminution 
of urine, constitute an unfavorable prognostic sign. In some 
cases, in a mild diphtheritic attack, urine may become scanty, 
highly albuminous, and death result. In some few cases blood 
may be found in the urine. 

Capillary Bronchitis. — Simon recommends careful surveil- 
lance of the secretion of urine in the management of capillary 
bronchitis in infants. The suppression of urine may be the 
principal cause of dyspnea. If this occurs, he gives digitalis in 
15 c. gm. (2}^ grains) doses of powdered leaves in infusion, 
three times in twenty-four hours. At the same time he places 
a cataplasm over the kidneys, and also uses dry cups. The 
cardiac contractions take on more regular rhythm and the uri- 
nary secretion is restored. 



URINE IN VARIOUS DISORDERS. 437 

Measles. — Montefusco found the urine diminished, chlorides 
diminished, sulphates and phosphates sometimes increased in 
this disease."^ Rarely was a trace of albumin found. 

Loeb has found propeptone (hemialbumin) in the urine of 9 
patients with measles out of 12, in which he examined the urine 
for it. The reaction was obtained, as a rule, for about two days 
at the beginning of the affection, after the temperature had be- 
gun to go down, but before the rash had disappeared. He 
suggests that perhaps the skin affection is connected with its 
formation. Nitric acid added cautiously to the urine, drop by 
drop, produces a white, flocculent precipitate dissolved by heat, 
but reappearing upon cooling, if propeptone is present. 

Suppression of Urine, — Cases of suppression of urine in chil- 
dren occur, especially in connection with the acute nephritis of 
scarlet fever, or in scarlet-fever dropsy without albuminuria. 
Cases of complete suppression have been known to occur in 
children after catching cold. Overdoses of drugs, as cantharides, 
turpentine, lead, and irritants generally, may cause it through 
hyperemia of the kidneys. Roberts reports a case in connec- 
tion with scarlet-fever dropsy without albumin, in which the 
child, seven years old, voided only two drachms in twenty-four 
hours ; it was of a deep saffron color, highly concentrated ; it 
contained no albumin, but casts were found. The total quan- 
tity of urine voided in the entire last seven days of life was but 
six or seven ounces. 

Janeway saw one case after measles in which a child of seven 
passed but a quart of urine during an entire week, without 
albumin, blood, or casts, the specific gravity being 1030. 

Eclampsia. — In eclampsia, Simon observes that the secretion 
of urine is entirely suspended, and subsequent discharge of it 
announces the approaching termination of the attack, or the end 
of a series of attacks. 

Fibroid Contraction of the Kidneys. — Fibroid contraction of 
the kidneys was noticed by Fenwick in a case of a girl of nine 
years, who had been healthy until about seven and a half years 
of age, when she had an attack of measles and was never sub- 
sequently well. Six weeks before death she was passing 50 
to 65 ounces of urine — specific gravity lOio to 1012 — with one 
fourth albumin and casts of various kinds. There was hyper- 
trophy of the heart and high tension. Ophthalmoscope showed 
double neuritis. A fortnight before her admission to the hos- 
pital she had a severe fit, was universally convulsed, and lay 
unconscious for three days. When she recovered consciousness 



* It is not stated whether the increase in these solids was relative or absolute; relative 
increase is probably meant. 



438 THE DISEASES OF CHILDREN. 

she was practically blind, but partly recovered vision. She died 
three months after the first complaint of visual defect. 

Dermoid Cyst. — Hair may be found in the urine coming from 
a dermoid cyst discharging into the urinary passages. Ralfe 
mentions a case in a child in which an apparent hernia was 
discovered, but was found to be irreducible. The child became 
ill and feverish, the urine cloudy and albuminous, and the 
swelling disappeared. Later the urine cleared up, and ceased 
to contain albumin, but an abundance of fine hair was passed 
with the urine. The hair, collected and examined, consisted of 
three varieties : (i) very fine, short, straight hair, closely matted 
together by a sticky, sebaceous substance, having somewhat 
the appearance of felt ; (2) short, crisp, curly hairs, somewhat 
resembling wool ; (3) some longer fibers, resembling in all re- 
spects human hair, colored either deep coal-black, or else bright 
vermilion-red, and from a quarter of an inch to two inches long. 
The discharge of hair caused the child no discomfort. 



CHAPTER III. 

ACUTE NEPHRITIS. 

Definition and Synony^ns. — Acute inflammation of the kid- 
neys ; acute Bright's disease. Under the head of acute nephritis 
are considered the various forms most common in childhood, 
as diffuse, exudative, etc. 

Etiology. — Scarlatina is the most common cause of the acute 
(diffuse) nephritis in those under sixteen years of age. In some 
cases acute nephritis is primary in children. Acute nephritis 
may result from administration of poisons, or be secondary to 
a number of disorders, as diphtheria, small-pox, typhoid, etc. 
Acute nephritis (exudative) may occur as a complication, and 
not as a sequela, of scarlatina, diphtheria, and many infectious 
diseases. Acute nephritis in children may follow exposure to 
cold. 

The scarlet fever nephritis is now regarded as chiefly microbic 
in origin, though it is claimed that exposure to cold will often 
induce an attack. 

Rasch believes that the ear may sometimes be the focus 
from which the kidneys receive the infection, inasmuch as he 
found a case of otitis media acuta, which was followed by acute 
nephritis. He points to the necessity of examining the ears of 
small children when the origin of infection cannot be found 
elsewhere. 

Pathology. — Cases of acute nephritis most commonly seen in 
childhood are post-scarlatinal. The tendency of modern inves- 
tigations is to show that this disorder is a complex state of both 
tubal and interstitial change ; hence the term acute diffuse 
nephritis. 

Delafield distinguishes two forms, exudative and diffuse, the 
former essentially transitory, marked merely by exudation of 
the albuminous constituents of the blood ; the latter by pro- 
duction of new connective tissue. Acute exudative nephritis 
is then not likely to become chronic, while diffuse nephritis 
proper is likely to persist. Clinically it is difficult to distin- 
guish acute exudative nephritis from acute diffuse, except in 
cases of exudative where there is excessive production of pus 
in which certain symptoms are found. (See Symptoms.) 

Symptoms. — The symptoms of post-scarlatinal nephritis are 

(439) 



440 THE DISEASES OF CHILDREN. 

usually the following: On the 14th, 20th, 21st, or 22d day aft- 
er invasion of scarlet fever there is usually increased tempera- 
ture, perhaps headache, pallor, vomiting, possibly convulsions ; 
micturitions may be increased in frequency, and pain be felt in 
back and region of the bladder. Edema is present, first in 
tissues about inferior eyelids, then in lower extremities, upper 
extremities, until finally there is general anasarca. Drowsiness 
or stupor may be present. Cough, difificulty of breathing, in- 
termittent pulse, together with scanty, bloody urine, highly 
albuminous and containing casts, complete the picture. Varia- 
tions in the symptoms may be noticed ; in some cases convul- 
sions are the first symptoms, in others obstinate vomiting. 
Goodhart speaks of a case in which hematuria, scanty urine, 
and asthenia were the only symptoms. Delafield speaks of cases 
in which the urine contains pus (acute exudative nephritis, with 
much production of pus), in which dropsy is absent or very 
slight and the entire clinical picture is that of acute meningitis : 
marked fever and prostration, restlessness, sleeplessness, de- 
lirium, headache, stupor. The patients lose flesh and strength 
and pass into the typhoid state. When such symptoms are 
encountered following scarlet fever, they are highly suspicious ; 
difficulty in establishing the diagnosis is encountered early in the 
disorder, when the urine may not be scanty nor contain albu- 
min, casts, or blood ; but later in the disease the last three 
may be found, though sometimes they are entirely absent. 
(In some cases no symptoms except the condition of the urine 
are noticed. Aldrich, of Minneapolis, saw a case following 
typhoid fever in which a boy of ten, during nine months of 
treatment, would not admit that he was sick, although during^ 
eight months of the time albumin averaged from a third to a 
sixth. Such cases are better regarded as sub-acute.) 

Symptoms of acute primary nephritis are often misleading, 
inasmuch as there is no history of scarlatina to arouse our sus- 
picions. 

E. L. Holt speaks of a number of cases, in which the symp- 
toms attracted attention to the brain or digestive system ; there 
was fever, rapid pulse, peculiar respiration, and nervous symp- 
toms. In two other cases, he found the predominating symp- 
toms, continuous temperature of a high, remittent type, 
dullness, apathy, anemia, and mild gastro-intestinal symptoms 
without dropsy or suppression of urine. The last two cases 
lasted 17 and 22 days respectively and both died. The tem- 
perature ranged from 101° to 105°. Goodhart mentions a case 
not following scarlet fever, in which the symptoms were as 
follows : the child felt sick, had stomach-ache and was feverish. 
She afterward vomited repeatedly, was pale, drowsy, ashy in 



ACUTE NEPHRITIS. 441 

appearance, with sub-normal temperature, cold extremities, 
and imperceptible pulse. The heart sounds were rapid and 
irregular. The urine contained one-tenth albumin and casts. 
Suppression of urine followed, continuing for many hours, and 
just before death she had convulsions. The disease lasted 
seven days. 

Seyournef^ has studied a type of albuminuria among children 
of the age of from eleven to sixteen months. A great many of 
the patients had been brought up on the bottle, having been 
fed on unsuitable food, causing distention of the abdomen or 
stomach, or occasionally enlargement of the liver, or intestinal 
disorders, accompanied by vomiting or diarrhea. He believes 
this special form of albuminuria to be of an infectious character, 
and traces it back pathogenetically to certain toxic substances, 
which are generated by abnormal fermentation in the bowels. 
These substances are absorbed by the bowels and pass to some 
extent into the kidneys. They produce congestion in the renal 
tissue, which may lead to inflammation of the kidneys. One 
of Dr. Seyournet's little patients had scarlet fever twenty-two 
days after convalescence from this albuminuria. It is evident 
from this fact, that it was not scarlatinal albuminuria. It was 
usually accompanied by anuria, whereby the congested condi- 
tion of the kidneys was intensified. With some of the patients 
the daily evacuation of urine was only half an ounce. In one 
case the patient passed no urine for more than forty-eight 
hours. Notwithstanding this, no uremic symptoms appeared. 
It was in most cases only the anuria which led to the urine be- 
ing examined for albumin. The result of the examination in 
in each case was positive. A strongly marked feature of this 
disease is the edema of the feet, sometimes also of the hands 
and of the eyelids and face, but the latter were not always af- 
fected. The quantity of albumin varied from a drachm to ten 
drachms per diem (60 to 160 grains, 4 to 40 grams). The 
duration of the disease was from two to four weeks. The treat- 
ment consisted in giving milk, which in some cases was mixed 
with lime-water. Systematic massage of the lumbar regions 
was also employed in order to relieve the congestion of the 
kidneys. Various drugs were also given. 

Another case recorded by Goodhart, was that of a boy, who, 
after being weaned from the bottle, had intense thirst, but was 
otherwise thought to be well. At the age of three he had a 
sudden and severe attack of fever and vomiting, from which he 
recovered. After his recovery he had night terrors, and became 
subject to severe attacks of tetany and periodic attacks of 



* The Lancet, 



442 THE DISEASES OF CHILDREN. 

vomiting. His urine was always of low specific gravity and 
sometimes contained albumin and sometimes not. There 
were no casts ; dropsy was absent. Once a month he would 
have a relapse, tetany reappearing, urine becoming scanty and 
loaded with albumin. He died in one of these attacks, coma- 
tose, and in a state of opisthotonos. 

It may be remarked here that in all obscure diseases of chil- 
dren, in which intestinal disorders are prominent, the urine 
should be frequently examined. 

An editorial in the Halmemannian, 1893, p. 417, calls atten- 
tion to the fact that albuminuria, without the well-known 
symptoms of Bright's disease, may occur in children. The 
younger the child, the less characteristic may be the symp- 
toms. A simple high fever, or vomiting, purging, and collapse, 
or drowsiness and mild convulsive seizure, or simply anemia 
may be the symptoms. Nephritis, without apparent cause, 
and practically without indicating symptoms, may occur in 
children even as young as six months. The excellent prac- 
tical suggestion is made that to collect the urine of infants for 
examination the child should be kept on pieces of well-boiled 
linen on a rubber pad for some hours, or on a sterilized silk 
sponge. Enough urine can be wrung out of these for pur- 
poses of examination. If retention be present, a small cath- 
eter may be used. 

Moussous speaks of two children who had nephritis in the 
course of rheumatic purpura. The symptoms were articular 
pains, hemorrhages beneath the skin and from mucous mem- 
brane of the alimentary canal, pains in the back, edema, occa- 
sional hematuria, continuous albuminuria, and in one case 
hyaline and epithelial casts. One of the children died from 
asthenia, and the kidneys were like the large white kidney, 
only not enlarged. He regards the cases as chronic diffuse 
nephritis. 

Hollopeter speaks of acute nephritis in a little boy, occur- 
ring after whooping cough. The child apparently recovered, 
when a relapse occurred and with it nephritis and uremia set 
in. There was edema of the lids and parts of the body, to- 
gether with stupor. Recovery followed. 

Longstreth describes the case of a colored boy of ten, picked 
up comatose in the street. His pupils were dilated. He com- 
plained only of abdominal pain, and had been busy running 
errands. Albumin and casts were found in his urine, and 
later he had more convulsions. No origin could be found for 
the case. 

Course. — Scarlatinal nephritis varies greatly as to course : 
we may find cases which begin to improve a week or ten days 



ACUTE NEPHRITIS. 443 

after they have begun ; or cases which, after progressing favor- 
ably, suddenly grow worse ; or cases which may be so violent 
in onset as to cause death in less than a day. Death occurs 
within the first eight or ten weeks usually ; after this time, if 
the patient lives, it is to be regarded as subacute or chronic, 
and may persist a number of years. 

The following cases, which recovered completely from scarla- 
tinal nephritis, illustrate the condition of the urine with reference 
to duration of the disorder. 

Case I. Boy. 14th of January urine was highly acid, con- 
tained moderate quantity of albumin, specific gravity 1026 ; 
sediment contained blood, pus, renal epithelium, hyaline, 
■epithelial, blood, and finely granular casts, the latter not very 
numerous. After this analysis the case became serious, with 
scanty urine and threatened uremia; but by March 13 not a 
trace of albumin nor any casts could be found, and the patient 
has been well ever since, now over a year. 

Case 2. Girl, sister of case i. January 23, blood, epithelial 
casts and considerable pus were found in the urine, albumin 
1-20 of one per cent, by weight ; after this the patient grew worse, 
urine diminished to half a dozen ounces per diem. Recovery 
was slow ; on April 20 a trace of albumin could still be found 
and one or two casts. On June 3 a few granular casts. On June 
28 no casts and a further analysis made December 15 showed 
the urine to be normal in all respects. 

Prognosis. — The patient's chances for recovery from scarla- 
tinal nephritis are two out of three ; but even in apparently 
favorable cases, relapses or heart failure may occur. 

Relapses may occur any time, and are marked by increase of 
dropsy, decrease of urine per twenty-four hours, increase of 
hematuria and albuminuria. The danger now is from uremia, 
or pulmonary edema. Favorable signs are subsidence of he- 
maturia, increase in quantity of urine per twenty-four hours, 
diminution in quantity of albumin and casts, lessening of 
dropsy. Signs of heart failure are sudden feebleness of the 
pulse, which becomes also irregular and sometimes slow. The 
respirations become rapid, extremities are cool, and death may 
result suddenly from collapse. 

Treat7nent of Acute Nephritis. — /. Preventive. — It has been 
held that a milk diet throughout, in scarlet fever, with avoid- 
ance of exertion, and of taking cold, in the third week, is suffi- 
cient to prevent the onset of acute nephritis. If, however, at 
that time the temperature again rises and the urine begins to 
diminish, with headache, edema, etc., then 

2. Hygienic. — Patient is to be put to bed, wearing woolen 
night-dress and wrapped in blankets. Jaeger night-clothing and 



444 THE DISEASES OF CHILDREN. 

bedding desirable. Patient to be sponged daily with tepid water 
containing a little alcohol ; each part of the body to be rubbed 
dry, after sponging, before another part is wet. Room to be 
about 70° Fahr. in temperature. Thorough ventilation to be 
secured. Diet : if urine be suppressed or nearly so, arrow- 
root gruel for two days ; then, if urine more abundant, milk in 
small quantity mixed with the gruel, rice in thin broth, plain 
rice pudding. In severe cases, no meat or fish for two weeks, 
and milk only in preparation of foods. Grapes, oranges, straw- 
berries allowable. After the first day or two give pure spring 
water freely. Such waters as Poland, Bethesda, Clysmic desir- 
able. Potatoes, especially sweet, allowable. When severe 
symptoms subside, exclusive milk diet. Try the entire milk, 
or if not borne, skimmed milk, a few ounces every two or three 
hours, lime-water and milk, milk of magnesia and milk. Or, if 
constipation, milk and Vichy, milk and carbonic water. Bear 
in mind also, peptonized milk, peptonized gruel and milk, pep- 
tonized milk toast. The milk diet should be continued for four 
weeks. 

3. Remedial. — The remedies most often found useful are 
mere. cor. terebintJi. ferrtim, digitalis and apiuni vims. 

The table on following page will serve as a help in differ- 
entiating :* 

Searle thinks mere. eor. the main remedy for acute nephritis, 
alternating it with aconite ox ferrum phosphoricum, and giving 
warm baths (98° to 100°), prolonged to half an hour or an hour. 
Woodward thinks nitric acid often serviceable, and a remedy 
which should not be forgotten. Gastro-intestinal symptoms, 
together with headache, are the chief indications for use of it. 

Joussetf relies mainly on belladonna, caiitharis, diUd apium 
virus. He thinks belladonna should be used in the beginning, 
when there is fever, headache, vomiting, together with scanty, 
bloody urine. He gives six drops of one of the first three dilu- 
tions in a glass of water, teaspoonful every two hours. Can- 
tharis he uses after the beginning when there is no fever, or 
when belladonna has reduced the temperature in cases where 
the urine is highly albuminous, bloody, scanty, and passed 
with much tenesmus. Dose as of belladonna; in severe cases 
drop doses of the tincture three times daily. 

Some clinicians advise acidum carbolicum and kali bichromicum 
in the earlier stages, following with mere. cor. or mere, cyan., and 
using apis in the later stages. When serous effusions are 
evident, arsenicum, bryonia, senega. 



* Table X on page 124 of Mitchell's " Diseases of the Kidneys." 

+ Paper translated from the French by the writer of this article for the Columbian Ex- 
position Congress, of 1893. 



ACUTE NEPHRITIS— LEADING REMEDIES. 



445 



< 


'-5 


o 

o 

;^ 

o 


Chills and fever very 
prominent symp- 
toms. 


Edema, especially of 
face, early and 
prominent. 


6J3 

CJ 
E 


> 


< 

r- 
C 


'T3 

c 

C 

c 

S 
o 


o 

c 
a; 
C 

s 

o 




b 

V 

IS 

(J c 

Sg 


C3 

ci 


o 

--^ 

S £ 

U 




s 

03 

O 

o 


T3 
C 

"5 
ex 

3.2 

rt ■>-> 

w. p 

o ►- 


SSI . 


C „ 

O 1* 

£ 6 S 

^ _«-; O 


a 

£ 



c 


g 


£ T3 

^ G 
0, G 

U 


5 


o 

(U 

B 

•*- 
o 

aj 

en 

rt 
o 

o 


o 

c 

C 
C3 

o o 


ii 

c -• 

<U C3 S 


g 

.s ^ 

O 


£.£ 

si 

hi 


-d gi^c.-^ 
■^ 5:h £ 

^ ^ ao 

ci S -^ 

oj'rt .£ 's^ £ 
i; )_ c/j CD ji 

^ o p <JJ t^ 

-^ ^ o ":= 


K 
O 
Q 

D 

s 

U 


ll 

SI 

cfi O 
O 


|1 


ii 


O 

« 

1| 


o 

c 

a 
<v 

n 

Q 


o 

G 

£ 
£ 

- £ 
U 



446 THE DISEASES OF CHILDREN. 

For the dropsy resisting apparently indicated homeopathic 
remedies, Tooker advises diuretin, which he has used success- 
fully in a number of cases. Severe dropsy, coming on after the 
acute stage of nephritis, is often easily reduced by diuretin.* 
In cases of mitral insufficiency with insufficient compensation, 
digitalis is given first to reduce the compensatory disturbance, 
then diuretin is administered for the ascites, and anasarca. Chil- 
dren from two to five may take from eight to twenty-five grains 
a day; children from six to ten as much as from twenty-five to 
forty-five grains in divided doses. The total amount for the 
day may be dissolved in four ounces of warm water, with ten or 
twelve drops of brandy, and say forty grains of sugar. In some 
cases the drug has been given for weeks without signs of cu- 
mulative action or diminished therapeutic effect. As a rule, if 
in six days it has no effect, it is useless to continue it any 
longer. 

Sambucus Nigra. — In full doses has been found to be a 
very prompt diuretec in acute nephritis with anasarca. 

In the anemia following acute nephritis, there should be one 
meal a day of solid food, meat with bread and butter ; during 
the rest of the twenty-four hours, milk. Bowels are to be 
opened daily by enema or simple laxative. Internally /err um, 
supplemented by inhalations of oxygen gas. Boudreaux's syrup 
of the protochloride of iron is an excellent preparation. In 
the case of a child whose urine was brought to me for examina- 
tion, complete cure was brought about by the use of Bou- 
dreaux's protochloride. The symptoms were dropsy, anemia, 
and albuminous urine, containing numerous hyaline casts. 

If ferrum fails, recourse may be had to preparations of malt 
and cod-liver oil. 

COMPLICATIONS OF ACUTE NEPHRITIS. 

Uremia. — In the treatment of uremia, with convulsions 
impending or already present, application of a large hot poul- 
tice to the loins should be made and it should be changed 
every three hours. The wet pack may be used with advan- 
tage to promote sweating; a thin blanket is wrung out of hot 
water, and the naked child is wrapped in it from chin to feet ; 
a dry blanket is then wrapped round it and loosely covered 
with a mackintosh. After an hour or so the wet pack is 
removed, and the child swathed in a dry blanket. The pack 
should not be continued for any excessive length of time. 
If necessary, the pack may be repeated at intervals of four to 
six hours. 



Amer. Pract. and News. 



ACUTE NEPHRI TIS— C OM PLICA TIONS. 447 

Cupping the loins is recommended, but is not suited to the 
case of young children. 

Purdy and others recommend blood-letting ; " if the child be 
of robust constitution, and the symptoms do not yield to 
other measures, from two to six ounces of blood may be taken 
from the arm, often with the happiest results."* 

When one convulsion follows another, or other of the lesser 
convulsive measures seem to threaten, Goodhart, instead of 
bleeding, prefers an ice-bag to the head and administration of 
chloroform, potassium bromide, and chloral hydrate, either by 
mouth or rectum. The benzoates may also be given internally 
to prevent recurrence of the convulsions. 

The symptoms of uremia are usually diminution in quantity 
of urine, increased headache, twitching of some part of the face 
or extremities, or a general epileptiform convulsion, affecting 
the whole body. There may be but one attack, or one may be 
rapidly succeeded by others again and again, in which case 
there is much danger. 

Searle speaks highly of lemon-juice in the treatment of 
uremia ; half a pint in all in twenty-four hours, each dose mixed 
with water. Pilocarpin is regarded as a dangerous agent in 
the case of children. 

Edema of the Tissues and Cavities, — Edema of the lung is a 
most serious complication. It often sets in rapidly ; the phys- 
ical signs are those of acute bronchitis, but the face is pallid 
or cyanotic, there is great dyspnea and distress, and the aspect 
of the patient is that of one not long to live. The bowels should 
be opened at once and such remedies as digitalis, strophanthus^ 
etc., given. Stimulants, if necessary, as brandy, champagne, 
aromatic ammonia. 

Hydrothorax occurs more slowly and is usually a part of the 
general filling up with water. It is a dangerous complication. 
Arsenicum is the principal remedy, together with general 
eliminative treatment. If any operation is to be performed, 
aspiration is the best for withdrawing the liquid. 

Dropsies of serous cavities, in general, require arsenicum; par- 
acentesis with a very fine canula is advised by Goodhart for ab- 
dominal dropsy, for relief of immediate symptoms. Yoxanasarca^ 
digitalis, strophanthus, caffein, the benzoates and diuretin are 
to be used first ; the legs may be punctured (simple acupunc- 
ture). Bowels to be opened freely and baths given. 

Vomiting. — Skimmed milk or iced Vichy, iced champagne. 
Glonoin is worth trying. Hot water will sometimes check the 
vomiting when other measures fail. Kreasote may be tried. 

* Purdy. 



448 THE DISEASES OF CHILDREN. 

Vomiting, in cases where there is uremia, is often an effort of 
nature and should not be checked too suddenly. 

Suppression of urine. — (See Uremia.) Give plenty of watery 
drinks, hot lemonade, cider, etc. 

Cardiac Hypertrophy. — Symptoms : displacement of apex- 
beat, accentuation of second sound, increased dullness. Digi- 
talis and convallaria, the latter in doses of 3 drops of the fluid 
extract. 

Acute Dilatation of the Heart. — Irregular or halting action 
of the heart, frequent, thready, fluttering pulse, cold extremi- 
ties, and frequent respirations are the symptoms. It is a very 
serious complication and likely to result in edema of the 
lungs. Length of the systole, want of sharpness, or shuffling 
quality may be noticed. 

The remedies are digitalis, strophanthus, and caffein. Good- 
hart advises tincture of digitalis in four or five minim doses 
every three or four hours, continued for a day or two, then left 
off for a day or two, and begun again, if necessary; digitalin 
in doses of 1-120 of a grain may be given instead; strophan- 
thus, in doses of from 2 to 5 minims of the tincture, or caffein, 
in doses of one or two grains, the latter together with sodium 
benzoate in water. He thinks strychnin in doses of i-ioo 
of a grain by subcutaneous injection one of the most valuable 
cardiac tonics that we possess. 

Collapse, with slow pulse (65 or even 50), perhaps alarmingly 
irregular, rapid breathing, cool extremities, is an exceedingly 
grave complication. Stropha7ithus is probably the best remedy. 

Diarrhea is a common complication and should rarely be 
checked completely unless there is great exhaustion, since 
elimination is promoted by it. 

Acidity of the Urine. — In some cases, the highly acid urine 
favors blocking up of the convoluted tubules with colloid mat- 
ter; for the purpose of diminishing the acidity, litJiia waters, 
as Londonderry, Buffalo, or other well-known alkaline waters, 
may be given, or lithium be^izoate in small doses, first decimal 
trituration; possibly grain doses of \.\i^ citrate of potash dis- 
solved in a moderate amount of water, and given every two to 
six hours. 

Granular effervescent citro-tartrate of sodium may be given 
in five-grain doses in water. 

SUBACUTE NEPHRITIS. 

This disorder may be either i-diopathic or a sequela of scarla- 
tina and diphtheria. Whereas the duration of acute nephritis 
is about four weeks, eight to ten weeks at most, that of sub- 



SUBACUTE NEPHRITIS. 449 

acute may be for months, or even years. The symptoms come 
on gradually and are chiefly the following : Anemia, dropsy, 
loss of strength, nausea, vomiting, diarrhea. The urine is not 
likely to be greatly diminished ; it may even be increased, but 
the amount of solids as compared with that of the water defi- 
cient ; i, e., the quality of the urine is poor. The arteries are 
usually relaxed, but sometimes contracted ; there may be 
inflammation of the retina. (Delafield.) 

1 . Hygienic Trcatmeiit. — Removal of patient to suitable warm 
climate, where out-of-door life is possible, as Southern Cali- 
fornia, the Bermudas, the Arkansas springs, Thomasville in 
Georgia, Tallahassee in Florida. High altitudes, rough ocean 
voyages and long railway journeys to be avoided. 

If the patient reside in a cold climate, he must be kept in- 
doors in stormy weather, and observe every precaution about 
catching cold ; wear woolens, etc. ; diet need not necessarily be 
limited to liquids, except in acute exacerbations. Patient may 
take as much solid food (of a non-nitrogenous character) and 
fats as he can digest. Excessive use of mineral waters of doubt- 
ful utility. The patient should void enough urine daily to 
excrete the normal amount of urea, and when dropsy is to be 
overcome, the amount of fluids taken by the patient should not 
exceed the amount of urine voided.* 

The same general hygienic treatment pertains to protracted 
forms of acute nephritis. The patient may have to be kept in 
bed for a time, but should be given fresh air as soon as it is 
prudent. 

2. General Treatment. — The patient's bowels should be kept 
in order and the skin moist and active. Massage is helpful, 
also inhalations of oxygen gas, when there is anemia. (See 
Anemia under Acute Nephritis.) 

3. Radical Treatment. — The remedies especially adapted to 
the sub-acute form are apis, digitalis, ferrum, mercurius cor. 
Where apis is indicated, headache is particularly noticeable. (See 
indications already given in table.) Digitalis is useful when 
edema and dropsy, together with cardiac failure, are prominent 
early in the case. There is some nausea, but the pain in the 
back is but slight. Indications for ferrum have already been 
given, as have those for mere. cor. (See table.) 

Boudreaux'siron is especially serviceable when ferrum is indi- 
cated. Ferrum phos. and the lactate of iron in the lower deci- 
mals are said from clinical experience to be useful. 

For the high tension, glonoin is the remedy, given in the 

* Delafield Med. Record. March 23, iSSg. In some cases no quantity of liquid ingested 
■will bring up the urea to normal, and the patient will excrete more urea when voiding- a 
smaller quantity of urine. See article bj- writer in Hahyiemannian (1893), 

D. C— 29 



450 



THE DISEASES OF CHILDREN. 



third decimal or upwards according to age of the patient. 
Symptoms of high tension are incompressible pulse, fullness in 
the head, or bursting headache, etc. Glonoin in triturations 
has been found less likely to cause aggravation than in dilutions. 
For coma without increased tension strophanthus, spartein, etc., 
in small doses. 

Prognosis. — Very few patients recover permanently. Some 
continue to get worse every way, and die within one or two 
years ; some get better after a few months, then become ill 
again, and so go on for years. 

Analysis of Urine. — The following is my analysis of the 
urine in the case of a boy of fifteen with subacute diffuse 
nephritis : 



Ingredients 


Grams 

per 
Liter 


Grains 

per 
ounce 


Grams 

per 
24 hrs. 


Grains 

per 
24 hrs. 


Urea 


10 
6 

0.8 


3 
0.4 


15 

9 
1.2 


140 
18 


Albumin 


Phosphoric Acid 



Volume of Urine in 24 hrs \ \^^Z ^^' 

^ ( 50 n. oz. 

Specific gravity 1012 



Sediment. — Blood corpuscles ; pus corpuscles ; epithelium 
from convoluted tubules ; hyalin, epithelial, granular, and 
fatty casts, together with a few waxy. 

Patient anemic, confined to bed owing to loss of strength ; 
edema of ankles and scrotum, face puffy, heart action at times 
irregular ; otherwise no symptoms. 



CHAPTER IV. 

PYURIA AND HEMATURIA. 

The principal diseases of childhood in which pus, with or 
without blood, is found in the urine are the following : Suppura- 
tive nephritis, pyelitis, pyonephrosis, cystitis, calculous disease, 
tuberculosis, cancer. 

When pus is found in the urine consult the table on page 452.* 
If blood is a well-marked feature in the urine, consult also 
the following table if 

DIAGNOSIS IN HEMATURIA. 



Blood from the 
kidneys. 


Blood from the 
bladder. 


Blood from the 

prostatic portion of 
the urethra. 


Blood from the 
urethra. 


Blood corpuscles 
spherical, small 
and brownish. 
Renal epitheli- 
um small round- 
ish, one - third 
larger than pus 
corpuscles. 


Blood corpuscles 
spherical, small, 
brownish, epithe- 
lium from blad- 
der often large 
round (middle 
layers). 


Blood corpuscles of 
normal disk-form, 
with central de- 
pression and red- 
dish-yellow color. 


Blood corpuscles 
like those from 
neck of the blad- 
der (prostatic 
urethra). 


Albumin more 
than blood ac- 
counts for. 


Albumin less than 
blood accounts 
for. 


Albumin less. 


Albumin less. 


Blood only during 
micturitions. 


Blood only during 
micturitions. 
Urine more and 
more tinged as 
bladder empties 
itself. 


Blood at the begin- 
ning of micturi- 
tion. Sometimes 
a few drops at the 
end only. 


Blood flows from 
meatus between 
micturitions, or 
may be squeezed 
out. Blood in the 
first glass only on 
micturition. 


Urine may con- 
tain casts. 


No casts. 


No casts. 


No casts. 


Clots rounded, 
correspondin g 
to diameter of 
ureter. 


Clots very large 
and irregular in 
shape. 


Clots leech - like, 
ovoid. 


Long, bougie -like 
clots. 



* Table X from Mitchell's 
■^Ilid. Table XII. 



Diseases of the Kidnevs." 



(451) 



452 



THE DISEASES OF CHILDREN. 





.£ 
'c £ 

2^ 

a, 
a, 

3 
73 


Urine in firstglass 
turbid, in second 
clear. 


Pus oozes from 
meatus between 
micturitions. 


1 

c 
o 

<2« 


Urine in first glass 
will respond to 
albumin tests. 


G . 
u <u 

n 

-^ o 

C<l 




u 

C 

C t^ 

.23 

S 

c 

D 
73 


M icturitions frequent 
and painful at begin- 
ning and end. Urine 
in first glass more tur- 
bid than that of sec- 
ond. 


Pus sediment shreddy, 
sometimes surmounted 
by blood. Shreds may 
be streaked with blood. 
Epithelium from mid- 
dle layers bladder 
(large). 


"^3 
'o 

3 
en 

3 

C 
O 

o 

CJ 


Urine may contain more 
albumin than pus ac- 
counts for. 


3 
en 
3 

OJ 
G 

= -0 

r. CD 
^ 03 
O !- 

.G " 




lU 

c 

■-313 

a, 

a, 

0^ 


Scalding urine, pain in 
passing water. Urine 
in both glasses equally 
turbid, last drops usu- 
ally very turbid. 


Pus sediment sticky, 
clings to the glass. 
Sediment contains tri- 
ple phosphate, bladder 
epithelia, bacteria. Pus 
corpuscles swollen. 
Epithelium of bladder 
(middle layers). 


03 

3 
en 

3 

G 

.2 

o a3 

03 G 
(3J .^ 

p^^ 


Urine contains but little 
albumin and that due 
to pus. Ammonium 
carbonate abundant. 


24 hours' urine usually 
normal or not in- 
creased. 




c 
1 


Acute: f e b r i le condi- 
tion, pain in back. 
Chronic : course insid- 
ious, symptoms may 
not be marked. 


Pus sediment flocculent, 
not shreddy nor sticky 
in uncomplicated cases. 
Pus corpuscles small. 
Pus plugs seen with 
microscope. Epitheli- 
um from pelvis. 


Reaction usually acid, 
may be alkaline if cys- 
titis complicates. 


Urine may contain more 
albumin than pus ac- 
counts for. (Not in- 
variable.) 


24 hours' urine de- 
creased in acute cases, 
greatly increased in 
chronic. 




IS 

a, 
a, 

3 
73 


Marked chills, emacia- 
tion, gastric disturb- 
ances. If uremia pres- 
ent, it is of a typhoid 
kind, with dry tongue 
and feeble pulse. 


Pus sediment like that of 
pyelitis, if urine acid; 
hyaline and granular 
cast possibly found. If 
urine alkaline, sedi- 
ment like that of cys- 
titis. Epithelium from 
kidney (small round) 


u 

CJ 

c3 

en 
U 

§1 

s| 


■ - - - 

Urine may contain more 
albumin than pus ac- 
counts for. (Not in- 
variable.) 


24 hours' urine de- 
creased in acute cases, 
greatly increased in 
chronic. 



HEMOGLOBINURIA. 453 

HEMATURIA : MISCELLANEOUS NOTES. 

Oliver reports a case in which a girl of eleven, who had been 
exposed to possible infection from her brother ill with typhoid, 
was taken severely ill and for thirty-five days had hematuria, 
together with high temperature. Blood disappeared from the 
urine on the fall of the fever. 

Sanford reports a case of possible malarial hematuria in a 
new-born infant, whose mother, a few days before confinement, 
had been treated for a mild attack of malarial fever. Hema- 
turia continued for four days, disappearing with the temperature. 

Moyer reports a case occurring in a child of five days with- 
out any appreciable cause. On the fifth day a slight icterus 
set in, unassociated with any disturbance of health ; it disap- 
peared in several days, the urine cleared up, and the child 
rapidly recovered. 

Chevalier reports a case in a boy of eight years whose mother 
lived in Mauritius, where hematuria is endemic. Recovery 
took place after prolonged treatment. 

HEMOGLOBINURIA. 

Sanders, of Munich, reports a case in a child three days old ; 
etiology uncertain. It was healthy up to the morning of the 
fourth day, when it became jaundiced, the urine highly stained, 
and death took place in a few hours. 

Ballets reports a case of paroxysmal hemoglobinuria, in the 
course of severe jaundice in a child of eleven, pointing toward 
the hemoglobinemic theory as possibly caused in this case by 
a species of auto-intoxication. 

Day reports a case of hemoglobinuria in a child, following a 
primary malarial paroxysm of the day previous. The stomach 
being unable to retain quinin, the drug was pushed by the 
rectum with success. 

Hemoglobinuria may possibly result from infection ; a child 
of two after ritual circumcision developed hemoglobinuria, 
became jaundiced, etc., and died. 

Dr. Charles Heitzmann of New York demonstrated to the 
writer a case of hemoglobinuria dependent upon creosote poi- 
soning. When the urine was fresh the odor of creosote could be 
made out, but after exposure to the air for a few hours the odor 
was not perceptible. The case occurred in an adult, but there 
is reason to suppose that it might occur in the case of children. 

If, in addition to pyuria or hematuria, a tumor can be made 
out, consult the table on page 454.* 



* Ibid. Table XIII. 



454 



THB DISEASES OF CHILDREN. 



< 

a, 

0) 

c 
<u 


ll 


6 
g 

.S 
c 

3 

O 

3 


s 

u 

u 

1— 1 


No variation in size. 


O 3 
0) 

oT u 

t. 3 

ll 


When very large, 
blood and blood casts 
in urine. 


3 

o 

ll 

3 ^ 
o o 

(/J 

3^ 


a 

(U 

3 



3 

(U ^ 


Great constitutional 
disturbances ; contin- 
uous elevation of 
temperature. Mark- 
ed rigors and sweat. 


<0 

c 
o 
?^ 


2 

o 

4) 


3 
o 

3 


bJD 


6 

N 

> 


C O ^J~ (U 

- 52 S 3 
o o S 

ac.S^ 

c § 3i: o 


3 OJ 
"3 X 

d ^ 
S| 

3 

S.2 

3 

"^i • 

3 3 1' 

-O 0.) ,^ 


|8 


a> +j 
J3 ^ 

.2 *- 
-O 3 

a 

Is 
'Hi 

^03 


X.3 « 
3 ^<*- 

3 


s 

>-> 

u 


o 
'5 


3 

y 

3 

G 
O 

;2; 


4) 

C 

C/2 


|§^ 
3 -S e . 

o S 5 ^ 
"i '5 ^ "o 

'^ N ^ 


c 

3 

as 


u 

(D 
O 

e 

2 
'C 

3 

a 


'H i ^ =3 ^ 

h; i?3 > a; 3 

Itll 

^ -^ !§ '5 ;^ 


a 

3 



3 

0) ^ 

5" 


3 >^ t« 3 ^3 
-3 G ^ 

— CL OJ tu 3 

'7] 


c 


0) 


c 

3 

c 
o 




6 

3 

c 
.o 

a 
> 
o 


3 
O 

1 

E 

(U ^_, 

si 

1) en 


61} 
3 

u 

CJ 

<u 

3 2 

^a 


■Si 



3 rt 


s 

_3 


3 

<u ^ 
C 3 
•r; oj 


•3 . i S .2 " 

S M S "a -S C 

;•; c "" S . 

1^ ^3 "U .tJ I-. >-■ cS 

> (u qs a; Oh 3 


o 

a, 

c 
o 

■73 


o 
'c 

3 IS 


3 
u 

C« -l-i 

3 <U 

o a 

3 O 


s 

u 

a 

3 


2 

2 

•-" o 

i| 
> 


"o bio 

si 

Cfl J- 

P-I 


a; 

c3 

.2 

3 

a 

<u 


-3 3 Tf 

^ 3^ G 
c«'^ 4J-^ 


-3 3 
T3 OJ 

a « 


i^.2 

3 . ^ 
-M a> cj 
■C ^ ^ 

c« 3 CJ 

3 rt 

^ U ^ 

i; — c/) 
• - -o cu 

'-^ 



DIFFERENTIAL DIAGNOSIS. 



455 



If no tumor can be made out, and there is suspicion that the 
pelvis of the kidney is involved, study the following :^ 

DIFFERENTIAL DIAGNOSIS IN TUBERCULAR PYELITIS, CALCU- 
LOUS PYELITIS, AND RENAL CANCER. 



Tuberculous Pyelitis. 


Calculous Pyelitis. 


Renal Cancer. 


Pus in the urine abun- 
dant, early, and con- 
tinuous. Great quan- 
tities of vibriones 
and micrococci. 


Pus in the urine in 
small quantities at 
first, slowly increas- 
ing. Pre ced ed by 
mucus. 


Little or no pus or de- 
bris. 


Hematuria not fre- 
quent, slight, and in 
night urine as well 
as day. Frequently 
absent for long in- 
tervals. 


Occasional attacks of 

slight, sometimes se- 
vere, hematuria after 
exercise, none at 
night, or after re- 
pose. 


Hematuria usually light 
at first, but later pro- 
fuse. Spontaneous, 
continuous, aggravat- 
ed at intervals ; and 
both after repose and 
exercise. Hematuria 
may be absent in chil- 
dren. 


Pain: — Greatest in 
the bladder, relieved 
when the bladder is 
empty. 


Pain: — Paroxysmal 
and radiating. Worse 
on motion. 


Pain not affected by 
movements. 


Pyrexia, marked. 


Pyrexia not marked. 


Pyrexia not marked. 


Emaciation, loss of ap- 
petite, etc. 


General nutrition 
good. 


Loss of flesh, anemia, 
cachexia. 



*Ihid. Table XIV. 



CHAPTER V. 

CANCER IN THE URINARY TRACT. 

Cancer of the Prostate. — Primary cancer of the prostate oc- 
curs chiefly in boys under ten and men over fifty. Engelbach 
found three cases in boys less than one year old. About seven- 
eighths of the tumors are carcinoma, the remainder sarcoma. 
In children the fatal termination is reached in a short time, in 
a few months at most. The most important diagnostic points, 
according to Belfield are: (i) Progessive emaciation and 
pallor; (2) Hard enlargement of lymph-glands in the groins, 
within the pelvis (detected by bimanual examination), and in 
Scarpa's triangle ; (3) irregular, nodular enlargement of the 
prostate. If recognizable cancer tissue can be found in the 
urine, the evidence is complete. 

The treatment should be directed to relief pain, cystitis, 
urinary retention, and rectal disturbance. 

Tumors of the Bladder. — The bladder tumors most common 
in childhood are of the polypous form (myxoma). Out of 
eighty-nine cases of papilloma of the bladder, collected by Dr. 
F. S. Watson, only one case occurred in males between ten 
and twenty years of age, and one case (female) between one 
and two years of age. In 100 cases of cancer of the bladder, the 
youngest patient was thirty years of age. Of sarcoma of the 
bladder, in twenty cases five were under twenty years of age. 

As to results of operation, Watson chronicles that in the 
case of two female children, each two years old, removal of 
benign growth (papilloma) resulted in death in both cases from 
exhaustion : one in six months, the other in sixteen. 

Renal Cancer. — Primary cancer of the kidney is said to be 
more frequent during childhood than in adult life. Whenever, 
therefore, an abdominal distention is found in a child, cancer of 
the kidney should not be forgotten. Renal cancer grows 
rapidly, more so than cancer in any other part of the body. It 
is more common in males. Out of 123 cases of primary cancer 
of the kidney, 45 occurred in children under ten. 

Hematuria is more frequently absent in children than in 
adults. 

Enlarged masses of lymphatics in young children may be 
mistaken for renal cancer ; but the latter is almost invariably 
(456; 



CANCER IN THE URINART TRACT. 457 

unilateral, while enlarged lymphatics are usually to be found 
on both sides of the abdomen. 

Encephaloid cancer is by far the most frequent form ; some- 
times tumors of a mixed character, weighing 25 or 30 lbs., have 
been met with even in young children. 

Children under five are especially liable to renal cancer ; 22 
out of 6j cases occurred at this period, and three others between 
seven and ten. Of the 25 cases mentioned two were one year 
old or less, six between one and two, six between two and three, 
eight between three and five, two between seven and eight, and 
one ten years old. Of 24 cases 15 were boys, and 9 girls. 
The etiology is obscure ; blows or falls are probably exciting 
causes only. 

Roberts cites a case typical of infantile renal cancer in a boy 
six months old. When born, the nurse thought he had a full 
stomach. A fortnight old he had severe pain and flatulency, 
but was pretty well after it until three months old, when it was 
observed that his abdomen was larger than it ought to be, and 
it continued to enlarge. Early in life he had had frequent at- 
tacks of diarrhea, stools like " boiled moist cabbage ;" later, 
would go four or five days without evacuation, the motions be- 
ing dry, hard, and yellow. Up to death he voided urine freely, 
and the latter was clear and free from blood. Appetite raven- 
ous, and thirst intense. Ten weeks before death he was much 
emaciated, and the abdomen measured 21 inches over the 
umbilicus, with universal dullness on percussion, except in the 
left hypochondriac and hypogastric regions. The abdomen in- 
creased in size three inches in two months. The child died when 
seven and one-half months old. Hounsell gave Roberts notes 
of a case in a male child of four years. The boy had a large 
tumor in the umbilical, right hypochondriac, and lumbar 
regions. Its surface was dull on percussion, and the dullness 
was continuous with that of the liver. The child was sallow 
and emaciated. The tumor had been detected three months 
before death, and had grown rapidly. Hematuria had been 
noticed shortly before the discovery of the tumor, which in- 
volved the right kidney, and weighed nearly eleven pounds. 

Sarcoma of the Kidney. — Dr. Charles Heitzmann, of New 
York, recently demonstrated to the writer, the diagnosis of 
small, round-celled sarcoma of one kidney, by means of micro- 
scopical examination of the urine. The patient was a child of 
six, and the diagnosis was confirmed hy post-mortem. The urine 
contained the sarcoma corpuscles, which are midway in size 
between red-blood corpuscles and pus corpuscles ; in addition 
to sarcoma corpuscles, the urine contained shreds of fibrous con- 
nective tissue, large bunches of it being abundant. The points 



458 THE DISEASES OF CHILDREN. 

in the diagnosis were, first, the sarcoma corpuscles, and second, 
the abundant connective tissue shreds. The locaHty of the 
tumor was decided by the relative abundance of epithelium 
from the convoluted tubules of the kidney. Uric acid crystals 
being present showed involvement of one kidney only. 

The diagnosis of sarcoma microscopically by the urine is not 
possible unless ulceration of the tumor be present, which in- 
volves the presence both of red-blood corpuscles and shreds of 
connective tissue. 

Sarcoma corpuscles are more granular than blood, and are 
without nucleus, or else are homogeneous. 

Sarcoma of the kidney is more common in children than in 
adults, and is sometimes congenital. The symptoms are about 
the same as carcinoma, namely : rapidly growing tumor in the 
region of the kidneys, with recurring attacks of hematuria. 
In sarcoma there is probably less pain and more hemorrhage 
than in carcinoma. Twelve cases of sarcoma, in which striated 
muscular fibers were found, are recorded by Roberts, always 
in young children. 

Prognosis and Treatment. — The prognosis is unfavorable and 
treatment wholly palliative. Nephrectomy is excluded in the 
case of children, as attention is not usually called to the dis- 
ease until recognition of an abdominal tumor, removal of which 
does not remove the disease. 

In the American Practitioner aud News is an account of sup- 
posed sarcoma of the kidney, in a girl three years and ten 
months of age. She had been under observation but a short 
time and the history was uncertain. There were no symptoms 
referable to the growth, and as yet no impairment of nutrition. 
A large, firm mass could be felt in the left side of the abdomen 
just below the line of the umbilicus, and could be distinctly 
seen when the child was upon the back. Posteriorly it could 
be detected in the lumbar region, and upon making pressure 
forward the whole mass could be felt to move freely. 

It was slightly nodular and hard and tense to the feel. It 
seemed to cause no discomfort or pain, and was not sensitive to 
pressure. The urine contained a few blood cells and broken, 
granular and hyalin casts. It was beyond doubt a kidney 
tumor, possibly a carcinoma. Carcinoma is, however, rare at 
this age, while sarcoma, if not common, is the most frequent 
kidney growth. 

At the New York Pathological Society, Dr. L. Emmett Holt 
showed a specimen from a patient two years of age. A tumor 
had been discovered in the right side five months before. 
There was but little impairment of nutrition and no definite 
symptoms. A diagnosis of sarcoma had been made and con- 



NOTES OA^ TUBERCULOSIS. 459 

firmed by operation. The growth weighed two and a quarter 
pounds, and was removed by lumbar incision. One week after 
the operation the patient was doing well. 

But one result could be expected in the first case without 
operation. The mass would increase in size and the child 
would waste and die. 

HYDRONEPHROSIS. 

Dumreicher, of Vienna, has reported a case of hydrone- 
phrosis in a girl of thirteen, the swelling in the abdomen dating 
from the tenth year. The tumor grew to enormous size, and 
to relieve dyspnea puncture was made and i8 quarts of a col- 
loidal, brown-colored fluid removed. 

In 13 out of 20 congenital cases mentioned by Roberts, the 
hydronephrosis was double. Two of these perished still-born, 
one lived six hours, one thirty, one thirty-six, while one died in 
twenty days, and another between three and four months after 
birth. One case mentioned by Hare lived thirty-eight years, 
and four other cases mentioned by Roberts lived from five and 
a half to twenty years. 

Imperforate urethra is a cause of hydronephrosis in children ; 
phimosis also. Congenital hydronephrosis is often associated 
with malformations of organs, as imperforate anus, harelip, 
club-foot, etc. 

NOTES ON TUBERCULOSIS. 

Among 315 tuberculosis children, Rilliet and Barthez found 
tubercle of the kidneys 49 times, or 15.7 per cent. From this 
it follows that the kidney is nearly three times more liable to 
deposits in tuberculosis children than in tuberculosis adults. 

Renal tuberculosis may occur as young as three and a half 
years. Dillreth mentions four cases out of a total of 31, 
which were between birth and ten years of age, and five cases 
between ten and twenty. 

Acute miliary tuberculosis is rather more frequently met in 
children than in adults, and the kidneys are less often invaded 
than the other organs. It usually invades both kidneys and is 
found in the cortex as miliary granulomata. 

In boys we sometimes see tuberculosis of the vesical neck 
without any discoverable testicular involvement, but usually 
the latter is present. Tuberculosis in children does not cause 
enuresis, so far as known. Dysuria is a symptom of tubercu- 
losis of the vesical neck, but irritability of the vesical neck is 
wanting. Evidence of involvement of 'the vesical neck is to be 



460 THE DISEASES OF CHILDREN. 

found when there is neither polyuria or dysuria, by frequency 
of urination or a tendency to bleed on even the gentlest intro- 
duction of an instrument. 

If even the«fewest and smallest shot-like nodules can be felt 
in the testes, suspicion of tuberculosis of the vesical neck 
should be excited, and repeated examinations of the urine made 
for tubercle bacilli. 

Bryson has seen six cases of tubercular nodules in the testes 
of young children which clearly dated from birth. In one case 
of a child of four, where no testicular involvement was discov- 
erable, a tubercular cystitis was complicated by secondary 
(phosphatic) calculi. 

SCROFULOUS KIDNEY. 

At a recent meeting of the Manchester Pathological Society, 
Dr. Railton showed specimens from a case of scrofulous kidney 
in a boy, aged two years and nine months, who had been an 
in-patient at the Manchester Clinical Hospital. A tumor was 
observed on the left side of the abdomen, extending from the 
ribs to the iliac crest, and reaching as far forward as one finger's 
breadth in front of the vertical line of the anterior-superior 
iliac spine. There was no movement of the tumor during res- 
piration, and the percussion note over it was dull. There was, 
in addition, some slight dullness over the apices of both lungs. 
One month after admission the child died of tuberculous 
meningitis. After death, the left kidney was found to be four 
or five times its normal size, and almost completely transformed 
into a caseous mass ; its pelvis and calyces were dilated, and 
contained purulent fluid. The ureter was completely closed, 
accounting for the fact that the urine showed nothing abnor- 
mal. The apices of both lungs showed infiltration, caseation, 
calcification, while that of the right showed, in addition, a 
small cavity. The brain showed a considerable quantity of 
fluid in the ventricles, exuded lymph in the space between the 
optic chiasma and pons and along the sylvian fissures, tubercles 
on the lower surface of the lateral lobes of the cerebellum and 
in the longitudinal fissure. Dr. Railton remarked that the 
disease in the left kidney had probably existed for a long time 
before that in the lungs, and had no causal relation to it, and 
that the meningeal tuberculosis was of quite recent date. He 
asked whether some distinction should not be drawn be- 
tween a slow caseating process like that in the kidney of this 
case, or as frequently witnessed in tumors of the cerebellum, 
and the rapidly disseminating process known as acute tuber- 
culosis. 



SCROFULOUS KID NET. 461 

Dr. Dreschfeld said that he would have expected to find, 
from Dr. Railton's description of the ante-mortem appearances, 
the kidney much larger than it turned out to be, but had often 
noticed similar discrepancies in other abdominal tumors. He 
did not consider that any real difference existed between this 
class of case and ordinary tuberculosis. The presence of 
bacilli in the urine would be conclusive evidence in a similar 
case, but in this the blocking of the ureter rendered such ap- 
pearance impossible. 



CHAPTER VI. 

CALCULUS IN THE URINARY PASSAGES. 

Etiology and Pathology. — In infancy and in adolescence oxal- 
ate of lime calculus predominates, associated with carbonate of 
lime. Children of gouty parents are themselves subjects of 
gravel. 

The deposition of clumps of urate of soda in the urinary pas- 
sages is not uncommon in the febrile attacks of infants and 
younger children ; it seems fairly probable that some of these 
clumps may be retained, either in the kidney-pelvis or in the 
bladder, and become the nuclei of future calculi ; hence, per- 
haps, the excessive frequency of calculi in children. 

The most frequent calculus in young children, then, is the 
urate, mixed with uric acid. The color is light fawn or grayish- 
yellow. Infarcts of urates are found sometimes in the renal 
tubes of young infants, and consist of irregular masses of am- 
monium and sodium urate, forming yellow-red lines, radiating 
from the papilla to the basis of the pyramids. They are not 
found in the kidneys of still-born children, but usually occur 
from the second to the nineteenth day after birth, and in some 
instances, as late as three or four months. They are generally 
regarded as physiological rather than pathological. 

The frequency of stone in the bladder is far the greatest un- 
der five years of age, and next, between ten and fifteen. 
Thompson's statistics show that of 1827 persons, who under- 
went lithotomy in England, 473 were under five years and 528 
between five and fifteen. 

Stone is said to be more common among the children of the 
poor than in those of the rich. 

Symptoms. — In young children, prolapsus ani, priapism, and 
bloody urine are signs of calculus disease. If the stream of 
urine is abruptly checked, suspect stone in the bladder or deep 
urethra. Retention of urine in a child often means a concretion 
impacted in the urethra. Examine the napkins in suspected 
cases for reddish-brown stains, or in older children, the urine, 
for evidences of uricemia, oxaluria, or phosphaturia. If the 
calculus is deposited in the kidney, there will be occasional at- 
tacks of slight, sometimes severe, hematuria after exercise, but 
little or none at night or after repose; pain is worse on motion ; 
(462) 



CALCULUS IN URINART PASSAGES. 463 

the urine may contain pus, in small quantities at first, slowly- 
increasing. 

Prognosis and Treatment. — In uric-acid calculus (renal) the 
prognosis, as a rule, is favorable. The treatment consists of 
copious drinks, warm baths, non-nitrogenous diet, and crude 
drugs, as sodium phosphate and benzoates in small doses. 

If the stone be in the bladder, and from the sediment is evi- 
dently uric acid or urates, and not oxalate or unknown, Roberts 
believes in trying solvent treatment, recommending 20 grains 
of citrate of potassiujn in three ounces of water every three 
hours, raising it soon to 25 grains, and after two months to 30 
grains. He has tried solvent treatment successfully in three 
cases of calculus of the bladder in children from four to twelve 
years of age, and makes the deduction that a continuously al- 
kaline state of the urine does not determine any precipitation 
of the earthy phosphates on the stone, so long as the urine is 
free from ammoniacal decomposition. 

Miscellaneous Notes. — Hance has recorded the accidental dis- 
covery of an oxalate-of-lime calculus in the body of an infant 
aged twenty months, who had died of pulmonary tuberculosis 
and whooping cough. 

Duret removed a vesical calculus weighing two ounces (60 
gm.) from the bladder of a child of six years. The stone was 
the size of a mandarin, smooth, with a center of brown sur- 
rounded by concentric layers of white. 

Langenbeck removed a xanthin calculus, size of a small ^^'g^ 
from a boy of eight. 

Taylor saw a xanthin stone weighing a quarter of an ounce 
taken from a child of four. 

Dulk removed a xanthin calculus weighing seven grains from 
the urethra of a boy. 



CHAPTER VII. 

URICEMIA. 

Synonyms and Definition. — The synonyms are lithemia, uric- 
acidemia, uric-acid diathesis, lithic-acid diathesis, lithuria. Dis- 
ease in which the blood contains excess of uric acid, or in which 
the latter, being imperfectly eliminated, accumulates in the 
system. 

Etiology. — Heredity and digestive disorders are the usual 
causes to which uricemia is referable. In children, uric acid, 
gravel or calculus, is frequently the result of debilitating illness, 
and from the very highly acid urine secreted by them under 
very slight disturbing influence. (Ralfe.) 

Pathology. — We do not know how or where uric acid is pro- 
duced in the body. In some cases there are deposits of uric 
acid or urates in the urine, without increase of total uric acid in 
the urine, and again the total uric acid may be in excess in the 
urine without deposits of uric acid or urates. Haig thinks 
changes in elimination, rather than in formation, responsible for 
the various clinical phenomena. 

Retention, for example, of uric acid in the system, is respon- 
sible for certain pains, while large excretion, by increasing 
arterial tension, causes others. 

Symptoms. — According to Sutherland the symptoms of uric- 
emia in children are of two classes : those due to presence of 
uric acid in the system, and those due to excretion of uric acid 
from the system. Symptoms due to the presence of uric acid 
in the system are as follows: The children have keen, precocious 
minds, small restless bodies, and are excitable and nervous. 
They are bright and amusing at one time, greatly depressed at 
another. They do not readily fall asleep at night, often talk 
in their sleep, wake early in the morning, are dainty feeders 
and like everything that is bad for nutrition ; are very subject 
to colds, and a chill in some form or other is the precursor of 
an acute attack. They sweat profusely on moderate heat or 
exertion and have cold hands and feet. The acute attacks are 
usually short, especially if the child is kept in bed, and are 
prone to recurrence ; during them the pharynx is relaxed and 
irritable, causing a loud, barking cough most marked when the 
child goes to bed, and possibly accompanied by some bronchial 
(464) 



URICBMIA. 465 

inflammation. The tonsils and adenoid tissue of the naso- 
pharynx are Hable to acute attacks leading to chronic thicken- 
ing and enlargement. There is frontal headache and symptoms 
of intestinal catarrh with furred tongue and foul breath. 
Slight irregularity of the heart occurs usually and the pulse is 
often small, weak, and irregular. The liver and spleen may be 
enlarged. In some cases abdominal pain is the only complaint, 
and this is sometimes found to be localized in the right iliac 
fossa. 

The symptoms due to excretion of uric acid from the system 
are the following : Pain is prominent ; renal colic may occur 
and pass for " stomach-ache." The pain may be present in 
any part of the urinary tract from the kidney downwards, is 
intermittent in character, and often so intense as to cause the 
child to cry out, especially in the middle of the night. Renal 
hematuria is frequently the first symptom and there may be 
more or less shivering, nausea, and sickness present during an 
attack. The pain is supra-pubic if the bladder is affected, and 
extends along the urethra to the meatus. The pain is often 
brought on by walking, and is increased during micturition, so 
that the urine is retained for a considerable period. Henoch, 
according to Sutherland, describes a case of convulsions, in a 
child five months old, due to reflex irritation from extreme 
dysuria, accompanied by passage of large uric acid crystals. 

As the kidneys are believed to secrete the uric acid from the 
blood, it is probable that great irritation may be caused in the 
tubules by the mechanical contact with the sharp particles. 
These may soon combine with the bases in the urine, are thus 
rendered non-irritant, and may be excreted without producing 
any disturbance in the urinary tract. Should the urine, how- 
ever, contain only a small amount of these bases, or should the 
passage of the uric acid through the tubules be hastened, pain 
will probably be present, and this is what we find, for ex- 
ample, in the screaming at night, when the urine is most 
acid, and in the pain caused by walking, when both from the 
vascular and muscular pressure, the kidneys are emptied of 
their contents more rapidly. 

The greater the proportion of solid to fluid constituents of 
the urine, the more marked will the pain be, while, if the 
watery constituents are abundant, pain will probably be entirely 
absent. It is a marked feature in the subjects of this diathesis 
that they drink in moderation, while they sweat profusely on 
slight exertion, with the result that the amount of urine passed 
is small. Many cases of intractable incontinuence are due to 
inflammation of the bladder, which is induced and kept up by 
the excessive acidity of the urine. Rectal pain, incontinuence 
D. C— 30 



466 THE DISEASES OF CHILDREN. 

of the feces, pain during defecation, prolapse of the rectum, 
and irregularity of the bowels will often be cured by directing 
the treatment solely to the condition of the bladder and urine. 
This may be confirmed on rectal examination by the tender- 
ness which is found on pressing forwards over the lower part 
of the bladder. Albuminuria is not infrequent, with or with- 
out hematuria, and is produced, like the latter, by mechanical 
irritation in the kidneys. The amount of albumin may vary 
from the merest trace up to one-half (on boiling), and tube 
casts may be present, usually fewer in number and of a more 
limited variety than in albuminuria from organic structural 
disease of the kidneys. A catarrhal inflammation in the pelvis 
of the kidney, or about the neck of the bladder, is manifested 
by the appearance of pus cells and epithelial scales in the 
urine. Dr. Milner Fothergill says that, "A large deposit of 
urates is a storm signal," and these storm signals are of great 
use in this latent disease. In a case of that of a little girl, 
aged ten years, who was apparently in good health, but whose 
urine contained urates and uric acid in such abundance as to 
attract special attention. This was soon followed by an at- 
tack of tonsilitis, pericarditis with delirium, endocarditis, and 
very severe chorea. Most of the above symptoms are illus- 
trated in the accompanying cases. There are some others in 
which the connection with uric acid may not be so readily 
admitted.^ 

Inasmuch as children in twenty-four hours excrete more uric 
acid per pound of weight than adults, they are thus by nature 
placed, as Haig observes, much in the position of an adult who 
eats largely of meat, hence are liable to uric-acidemia. The 
symptoms are gastro-intestinal disturbance, loss of appetite, 
headache, and slow pulse. 

Children fed on meat and meat extracts, often suffer from 
gastro-intestinal derangements, skin diseases, and early mi- 
graine ; in these patients rheumatism and its most serious man- 
ifestations should be expected early. Haig mentions a case of 
hemoglobinuria, in which a child, aged fouryears and ten months, 
was subject to attacks of cold and shivering, during which he 
passed high-colored urine. Before each attack he felt more than 
usually well, but his bowels were constipated ; just before the 
attack he yawned a great deal, his pulse was slow, and he com- 
plained of headache. Haig thinks, in this case, that the blood 
in the urine was due to a uric acid storm. 

In general, when children present a number of vague and 
anomalous symptoms, uricemia may be suspected and the urine 



Southerland, British Med. jfournal^i 



URICEMIA— TREA TMEN T. 46 7 

should be examined. According to some authorities, 30 per 
cent, of all children, and especially those at school, have neu- 
rasthenia, and other incomplete expressions of defective meta- 
bolic action. 

In cases of colic, examine the napkins of young children for 
reddish-brown stains, and look for prolapsus ani, priapism, and 
bloody urine as signs of calculous disease. If the stream of 
urine is abruptly checked, suspect stone in the bladder or deep 
urethra. Retention of urine in a child often means a concre- 
tion impacted in the urethra. 

The Urine in Uricemia. — The urine may be clear when 
voided, but soon becomes thick and opaque, or covered with a 
delicate film or pellicle, exhibiting faintly a play of prismatic 
colors ; or in a few hours their is seen in the sediment a deposit 
of free uric acid—" red pepper " crystals. The chamber vessel 
in such cases becomes covered with a slimy pinkish coating, dif- 
ficult to remove. 

In some cases the above condition may be absent ; if quanti- 
tative analysis of the urine shows deficient elimination of uric 
acid, especially if there is increase in the urea-uric acid ratio, 
while at the same time the symptoms described above as due 
to uric acid in the system are present, the condition may yet 
be one of uricemia. 

What the normal urea-uric acid ratio may be is difficult to 
determine, as we yet have no method for the quantitative esti- 
mation of uric acid which is not open to criticism. Haig, using 
Haycraft's method, asserts that it is 33 to i; Yvon-Berlioz put 
it at 40 to I ; Parkes at 60 to i; Olof Hammarsten from 50 to 
I, to 70 to I. In new-born infants, and in the first days of 
life. Mares puts it at about 13-14 to i. 

Treatment. — Speaking of the treatment of uricemia head- 
ache, E. C. Seguin makes the following sensible suggestions ; 
which apply to uricemia in general. 

*' The diet should consist of a minimum of sweet and starchy 
foods, a moderate amount of meat, an abundance of green 
vegetables, milk, eggs, poultry, and fish. There should be 
regular exercise in addition to play. Cold baths or sponges 
may be taken. The patient is to have plenty of sleep and 
plenty of water, especially at meals, as, for example, the mild 
lithia waters." 

In my opinion, this is the best general regime for uricemia 
which has been published. I lay especial stress on the im- 
portance of allowing the uricemic child plenty of sleep. For 
some reason not altogether plain, sleep is apparently one of 
the best " antidotes " to the uric acid poison which there is. 
Rousing a uricemic patient before he has completed his full 



468 THE DISEASES OF CHILDREN. 

quota of sleep is an act of cruelty. The worst cases of uric- 
emia are those in which insomnia is established, for sleep, and 
plenty of it, is the great desideratum in treatment. 

Copious drinks, and in some cases warm baths, are advisable. 
There are, however, some uricemic children who do not take 
kindly to too frequent baths of any kind, and become wakeful 
and restless if the latter be taken at night. 

Remedies. — In the case of children the leading remedies are 
mix vomica, calcarea carbonica, and lycopodium. Bryonia, podo- 
phyllum, arsenicum, belladonna, cantharis are also needed at 
times. If the case is one of gravel or calculus, berberis, uva 
ursi, etc. 

When the urine is deficient in water, the solids being rela- 
tively in excess, color high, red sandy sediment of uric acid and 
urates, or whitish sediment of urates mixed with pus and 
mucus, possibly even blood, together with dull pains in the 
kidney, relieved by voiding urine, lycopodium is the remedy ;^ 
nux vomica when disturbances of digestion are the root of the 
evil, and calcarea carbonica in typical subjects. In one case 
nux vomica 3x, alternated with calc. carb. 6x, gave marked 
benefit in a short time. 

If there is much blood in the urine thlaspi should be tried 
(tincture, 15 to 30 drop doses). 

As to the use of lithia waters, the following may be said : In 
some cases while they diminish alkalinity temporarily, the 
urine may become later more acid than ever. In which case 
copious draughts of pure spring water are better. 

The following case of uricemia has come under the writer's 
treatment : Girl, four years of age, light complexion, restless, 
nervous ; is somewhat puffy under the eyes, much irritation of 
genitals with prolapse of labial folds, brick-dust sediment in 
the urine; urine scanty, urea 131^ grains to the ounce (28 
grams per liter), phosphoric acid i grain to the ounce (2.3 
grams per liter), albumin faint trace, acidity increased, sedi- 
ment contains urates and uric acid. Lithium benzoate, third 
decimal trituration, was given four times daily with benefit. 
Removal to the fresh air of the country restored patient to 
health. After returning to the city the urine after a time be- 
gan to show much uric acid again on the advent of digestive 
disturbances. Nux 3X and calc. carb. 6x were then given and 
with beneficial results. 

Miscellaneous Notes. — Haig saw a case of splenic leucocy- 
themia in a boy, aged ten. Examination of the urine revealed 
the ratio of uric acid to urea to be i to 13.8 instead of i to 33, 



H. N. Lyon, Medical Visitor^ 1890. 



URICEMIA. 469 

the normal. The child was put on a mixture containing 
dilute nitro-hydrochloric acid three times a day before meals 
and another mixture containing salicylate of sodium gr. x and 
Sp. Am. Arom. m. xv three times a day after meals, with im- 
mediate improvement and rapid recovery. 

In two cases of Raynaud's disease in children, Haig found 
the ratio of uric acid to urea to be enormous, sometimes as high 
as I to 8.3. Under nitro-glycerin the patients improved and 
the uric-acid urea ratio fell to as low as i to 53 in one case. 

In the case of children of markedly gouty and rheumatic 
families, or of those in whose families bilious attacks, head- 
aches, or epilepsy are prominent, Haig thinks a decided reduc- 
tion of the animal nitrogen in their food is strongly indicated 
as a prophylactic measure. 

Seguin recommends dilute nitro-inuriatic acid, 3 to 10 drops 
in a tumbler of water after meals. Strong alkalies or lemon 
juice, if used, should be given three or four hours after meals. 



CHAPTER VIII. 

DIABETES MELLITUS. 

Definition. — Diabetes mellitus is a disease characterized by 
persistent presence of sugar in the urine, together with polyuria. 

Etiology. — Heredity and especially a phthisical history. Next 
to heredity, previously existing diseases, notably gastric ca- 
tarrh. Diabetes mellitus in children has been known to follow 
typhoid fever and purpura hemorrhagica. Over-exertion, pro- 
fuse perspiration, and cold are said to have caused at least one 
case ; falls and blows on the head are etiological factors ; also 
daily exposure to wet and cold, and cold baths. 

Transient glycosuria in children has succeeded malarial dis- 
ease, measles, immoderate eating of saccharine matters and 
even fatty substances, as well as indiscriminate eating, with 
daily exposure to wet and cold. (Stern.) 

Dr. John A. Larrabee thinks it can be shown that diabetes 
is connected with inherited neurotic tendencies. Epileptic, and 
nervous, hysterical parents often leave this legacy to their chil- 
dren. In his opinion, X\\^ fons et origo mali is a changed polar- 
ity of the nervous system in the medulla, without observable 
lesion. 

Schnee thinks diabetes intimately connected with syphilis ; 
he speaks of making the following " discovery :" " Diabetes is 
an hereditary, constitutional disease ; and the etiological ele- 
ment of this disease is lues contracted by some ancestor." 

Kiihl's observations on diabetes in children are that the in- 
fluence of heredity is as follows : parents of diabetic children 
either have diabetes or some nervous malady. He regards 
traumatism as one of the causes. He finds that mild cases 
may become severe more quickly under the influence of trau- 
matism. 

Loomis mentions a case in a female child twelve years of age, 
who, after fourteen months' illness from Bright's disease, eigh- 
teen months subsequent to scarlet fever, suddenly died of 
diabetic coma. 

Age. — Out of 117 cases in children, Stern found 6 under one 

year of age, i seemingly born with it ; 7 over one year ; 3 over 

two years ; 7 over three years ; 6 over four years ; 5 over five 

years ; i over six years ; 6 over seven years ; two had completed 

(470) 



DIABETES ME LL IT US. 471 

•eight years ; 8 were nine years old ; 6 were ten ; 9 were eleven ; 8 
were twelve ; 9 were thirteen ; 5 were fourteen ; 4 were fifteen ; 
28, age not given. They were all of the better class and only 
one Jewish. 

Out of 618 cases of all ages, W. J. Scott found only 4 under 
ten years. One was fourteen months. 

Out of 140 diabetic cases of all ages, Seegen found none be- 
tween the ages of one and ten, and but 5 between eleven and 
twenty. 

Out of 380 cases of all ages, Mayer found but i case under 
ten years of age, and 4 between ten and twenty. 

Nagle, quoted by Fowler, reports 4 deaths from diabetes 
mellitus in children under five years, in the years 1878 to 1887 
inclusive, in New York City, population 1,400,000; 29 deaths 
between five and twenty years. 

Prout, out of 700 cases, saw only one in a child of five, and 
about a dozen between eight and twenty years. 

According to Roberts, diabetes is rare under five years of age. 
In the reports of the British Registrar-general from 1851 to 
i860, ten deaths from diabetes in children under one year of 
age are registered in England and Wales, with a population of 
19,000,000, and 32 under three years of age. 

West saw only one case at three and a-half years. 

Schmitz, out of 21 15 cases of diabetes, saw 85 under twenty 
years of age. Ten were from one to ten years old, and 75 were 
from ten to twenty years old. Hereditary predisposition, he 
found in 998 cases, and he has seen five, six, up to eight or ten, 
and even twelve cases in one family. In some cases the pre- 
disposition was congenital, but not hereditary, brothers or sisters 
being diabetic. 

Isenflam saw a family in which eight children of healthy 
parents all died of diabetes after reaching their eighth year. 

Sex. — Female children are more susceptible to the disease 
than males.* 

Out of 78 cases. Stern found 47 females and 31 males. 
Simpson says that the proportion of males to females varies 
distinctly with age, being about equal up to ten years, and 
from that up it is more frequent in the male. 

Pathology. — No constant lesion has been found which distin- 
guishes diabetes mellitus. Pavy's idea is, that the whole trouble 
is due to imperfect de-arterialized venous blood, consequent 
upon vaso-motor paralysis, especially of the vessels of the 
chylo-poietic system. Modern research has shown that in some 
cases there is lesion of the pancreas. Larrabee's opinion is, 

* Kiihl. 



472 THE DISEASES OF CHILDREN, 

that there is changed polarity of the nervous system in the 
medulla, without observable lesion. 

Sympto7ns and Complications. — Diabetes sometimes manifests 
itself in children by wetting of the bed, and in all children in 
which this symptom is noticed it is prudent to examine the 
urine for sugar. In sucking babes, loss of flesh is sometimes 
the first noticeable symptom. 

The usual symptoms are persistent glycosuria, polyuria, 
polydipsia ; hunger, which may sometimes be ravenous, and 
emaciation. 

Complications of diabetes are coma, albuminuria, phlegmon- 
ous and gangrenous processes, erysipelas, pruritus, eczema, 
disturbances of sight, cystitis, and various other disorders. 

Fichtner saw a case in a girl of ten years, among whose 
symptoms were abolition of knee-reflex and diffuse retinitis. 
(Acetone was found in the urine, but not oxybutyric acid.) 

According to Litten, sudden blindness in young diabetics 
sometimes occurs. There is no affection in which disturbances 
of sight are so frequently met as in diabetes. All the ocular 
tissues, viz., the cornea, iris, crystalline lens, vitreous humor, 
retina, muscles, etc., may be affected, but changes in the crys- 
talline lens are the most common of the ocular manifestations 
of diabetes. 

The causes of diabetic cataract are but little known. Ac- 
cording to Seegen, it is to be attributed to the presence of 
exaggerated glycosuria and diabetic cachexia, and is always 
bilateral. 

Seegen's explanation holds good only in young patients un- 
der twenty years of age, seeing that in old people diabetic 
cataract is often unilateral, while it may be associated with but 
moderate glycosuria. 

In two cases under Litten's observation, cataract developed 
with amazing rapidity, the evolution being complete in the 
space of a few hours. 

The first patient was a girl, aged seventeen, in a cachectic 
condition, excreting about twelve ounces of sugar in the 
twenty-four hours. There was complete loss of sight on the 
right and imperfect vision on the left side. She was operated 
on by Dr. Hirschfeld, the lens being dislocated in the anterior 
chambers, where it was rapidly absorbed. The patient's sight 
has considerably improved since. 

The second case was identical with the one just described. 
No operation was performed, and the patient is now absolutely 
blind. 

Death has been known to follow operation for double cata- 
ract in a diabetic child. 



DIABETES MELLITUS. 473 

Diabetic Coma. — Coma is more common in children than in 
adults, and sudden deaths from it have been noted. Early rec- 
ognition of diabetic coma is very difficult and in some cases 
impossible, but it may be said in general that any sudden im- 
provement in the condition of the urine and objective symp- 
toms, not confirmed by subjective sensations on the part of the 
patient, should put the physician on his guard; reduction, for 
example, of excessive appetite to below the standard for a 
healthy child ; unexpected and unexplained loose movements 
when constipation had previously been the rule ; peculiar ace- 
tone odor to the breath, suggesting a mixture of chloroform 
and acetic acid ; acid eructations and nausea, with or without 
vomiting ; general prostration and disinclination to exertion : 
tendency to drowsiness, even in the daytime, with low spirits 
and despondency ; attacks of dizziness, frontal headache, neu- 
ralgic pains, accelerated pulse with or without decrease in 
volume. After a variable period of indefinite symptoms like the 
above, the patient will complain of a feeling of depression, is 
restless at night, eats nothing, has colicky pains, vomits matter 
sometimes having acetone odor, has sense of constriction about 
the thorax causing deeper breathing than usual ; the mental 
condition varies from excitability to mild talkative delirium, 
alternating with drowsy or stupid intervals. 

Gastro-intestinal derangements seem to stand in causal rela- 
tion, and coma may follow any unusual strain on the diges- 
tion, as also great fatigue; for instance, that of a railroad jour- 
ney. If a sudden onset of nervous symptoms be noticed when 
the patient has been put on diet, the latter should be relaxed.* 

The order of symptoms in diabetic coma is often as follows : 
Dyspnea, great excitement and wildness, benumbing of the 
senses, coma. 

Sudden death from diabetic coma is possible in cases like the 
following : Sugar in the urine not controlled by diet and 
medication ; patient extremely weak ; lower extremities edema- 
tous ; tongue red, raw and glazed ; mouth and throat covered 
with aphthous patches ; uncontrollable diarrhea; acute inflam- 
matory affections of the lungs present, or, earlier in the disease, 
chronic pneumonia.f 

The urine in diabetic coma is diminished in twenty-four 
hours' quantity, and in amount of sugar. There is extreme 
acidity, and the urine may have the acetone odor. Albumin 
in small quantity is usually though not invariably found. The 
so-called ferric chloride reaction is sometimes noticed. :[; 



* From Mitcheirs " Clinical Study of Diseases of the Kidney," second edition, page 380. 
f Ibid.^ page 379. 
\ Ibid.^ page 3S1. 



474 THE DISEASES OF CHILDREN. 

Cystitis. — This disorder may occur in connection with dia- 
betes. Teschemacher records a case of a boy of eleven in which, 
on the advent of vesical catarrh, the glycosuria disappeared, 
reappearing with the improvement in the vesical condition. 

Effect of Mental Excitement. — The influence of mental 
excitement on glycosuria is shown by Teschemacher in an ac- 
count of a very interesting case. A delicate boy of seven, 
hereditarily predisposed to diabetes, being attacked by this 
malady, was put on restricted diet, when the sugar, which at 
first was 4 per cent., fell to 0.35 per cent., and subsequently 
disappeared altogether. Soon after this he was attacked by a 
dog, which sprang at him and he fell to the ground, where he 
lay half unconscious with terror. He was carried home and 
put to bed. Trembling at first and speechless, he lay in bed 
for some hours before he partook of food, while he repeatedly 
asked for drink. Next day he was brought to Teschemacher, 
who examined the urine, and was astonished to find 3.3 per 
cent, of sugar. According to the mother, the quantity of urine 
passed was increased. Restricted diet was again ordered. On 
the following day the sugar stood at 2.4 per cent., two days 
later at only 1.5 per cent., and at the end of eight days it had 
entirely disappeared. This case furnishes a striking example 
of the relapse of glycosuria after great mental excitement. 
Dietetic errors were strongly denied by the mother, and the 
ingestion of milk once in measured quantity could not have 
led to it, as the amount of sugar passed was greatly in excess 
of the lactose in the milk. 

In my own opinion, the effect of mental excitement and 
psychical influences in general on diseases of the urinary or- 
gans has not received the attention it merits. In my work on 
Bright's disease I have advised the strictest attention to psy- 
chical influences throughout the entire treatment. This is espe- 
cially needful in the case of children who have mental terrors and 
annoyances from which adults are free. Few writers on diseases 
of children pay attention to the difficulties which lie in the way 
of successful treatment of many disorders in nervous, sensitive 
children, the real root of whose diseases is often found in men- 
tal suffering consequent upon depressing psychical conditions. 

The Urine in Diabetes Mellitus. — Complete analyses of the 
urine of children are seldom reported. Tyson records a case 
in a girl four and a-half years of age who passed sixty-five to 
two hundred fluidounces of urine per diem, specific gravity 
ranging from 1027 to 1040, sugar fifteen to thirty-four grains 
per ounce. This child died at five years of age. 

Purdy gives figures of an analysis made in one case, which 
will be found under the caption '* Reports of Cases." 



DIA BE TES MELLIT US. 



475 



I have been sufficiently fortunate to have the twenty-four 
hours' urine collected several times in one case of a boy of ten. 
The following is a complete report of analyses made by me : 



First Analysis. 


Second. 


Third. 


Fourth. 


Fifth. 


\'olume of urine in 24 hours | ^j-ro'c'^c^' 


42 fl. ozs. 
1250 c. c. 


70 li. ozs. 
2000 c. c. 


85 fl. ozs. 
2550 c. c. 


33 fl- ozs. 
1000 c. c. 




650 c. c. 


1150 c.c. 
S50 c. c. 
i^ to I 


1750 c. c. 
860 c. c. 








Ratio of day to night .... 


I to I 


2 to I 




Urea, grams per litre 


27 

34 

540 


II 


s 

2^ 
12% 


29 
133^ 
29 
450 




5 




Urea, grains per 24 hours 


350 






2 

I 


0.9 
0.5 


0.65 
0.30 


2.12 
I. 


Phosphoric acid, grains per ounce 


Phosphoric acid, grams per 24 hours 


2-5 


i.S 


1.66 


2.12 


Phosphoric acid, grains per 24 hours 


40 


28 


25 


32 


Ratio of urea to phosphoric acid 


13 to I 


12 to I 


8 to I 


14 to I 


Sugar, grams per litre 40 





36 


58 


6 








27 
14S 


3 

6 


Sugar, grams per 24 hours 70 




72 


Sugar, grains per 24 hours 10S5 




1II6 


2295 


92 


Sugar, per cent 4 


O.I 


ZV-, 


S 


3^ 


Ratio of sugar to urea . 




3)^ to I 


12 to I 


0.2 to I 




Specific gravity 1030 


I02S 


1036 


1037 


1029 


Acidity Normal. 

Sediment Uric acid. 


Deficient. 

Calcium 
phos. and 

oxalate. 


Normal. 


Normal. 
Urates. 


Increased. 
Uric acid. 



The urine, then, fluctuated between 33 and 85 fluidounces ; 
the specific gravity between 1028 and 1037 ; the sugar between 
one-tenth and 5 per cent.; the urea between 195 and 540 grains 
per twenty-four hours; and the phosphoric acid between 25 
and 40 grains per twenty-four hours. The greatest fluctuation 
was in the ratio of sugar to urea, which ranged from 0.2 to i 
to as high as 12 to i. The first analysis was made three months 
before the fifth. 



476 THE DISEASES OF CHILDREN. 

It is now more than a year since I saw the case in consulta- 
tion. The patient is still alive and reported to be improving. 
Diabetic diet reduced the quantity of sugar, but did not im- 
prove general condition of the patient, who is now on mixed 
diet, avoiding, however, sugar. 

In the case of a girl of twelve years of age (analysis made by 
my assistant, Dr. R. W. Lane), the figures were as follows : 

Urine for 24 hours, 1890 c. c, 93 fluidounces. 

Urea, 23 grams per litre. 

Urea, 43 grams per 24 hours. 

Phosphoric acid, i gram per litre. 

Phosphoric acid, 1.89 grams per 24 hours. 

Sugar, 3 per cent. 

Specific gravity, 1035. 

Analysis made August 30, 1893 ; patient said to be losing 
flesh gradually, and sugar still present. (February, 1894.) 

Acidity. — According to Derignac, the total acidity in diabetic 
urine increases with the proportion of sugar, with that of phos- 
phoric acid, and that of urea. It always increases at the 
moment of the appearance of attacks due to the presence of 
acetones. It constitutes, then, an important prognostic sign, 
and permits the physician to foresee these attacks, and enables 
him to overcome them by appropriate therapeusis. 

PJiospJiatiiria. — In two cases in diabetic children, Cerne 
noticed excessive phosphaturia, each case presenting foci of 
gangrene. Purdy mentions " excess of phosphates " in his 
case.* 

Acetone. — This substance, and also diacetic acid, oxybutyric 
acid, etc., have already been mentioned. 

Prognosis. — The prognosis in children's cases is bad. Seven- 
ty-five per cent, of the cases observed by Stern died. Of 
seventy-seven cases traced by him to a termination, fourteen 
recovered, seven improved, four remained unimproved, and 
fifty-two died. It is worth while, however, to note that the 
prognosis is not so hopeless as older authorities would have us 
believe. 

Course. — The disease runs a more rapidly fatal course in 
children than in adults, but the duration of the disease varies 
greatly. In thirty-four cases reported by Stern, the shortest 
died in two days, the longest was still alive at the end of five 
years; in seven cases death took place in one month, in all but 
one, which recovered. Seventeen lasted less than a year, and 
of these, seven were cured. Ten lasted over a year, and not 



* It would be clearer if writers would specify whether they mean excess of PaOg, or 
simply an abundant sediment of earthy phosphates. In the case which I saw there was 
neither condition. — C. M. 



DIABETES MELLITUS. 477 

one recovered. As ?c rule, the smaller the child, the quicker 
the course of the disease ; exceptions have been noted ; thus, 
a child of four died after two days of diabe"- and a child born 
with diabetes, recovered in eighteen months. 

Cases are reported by Prevost, Tyson, Deane, Henricius, 
Roberts, Kelly, Becquerel, Drummond, Anderson, Frew, D. P. 
Allen, Rachford, De Bary, and McCrea, which were fatal in the 
following time :^ 

Six days, Seven days, Nine days, Eleven days, 

Three weeks, Six weeks. Six weeks. 

Three months, Four months. Five months, Six months, 

Nine months, Twelve months, 

Eighteen months. Eighteen months after observation. 

Kelly's case was a boy of ten, previously healthy, who died 
in eleven days from diabetes following over-exertion, profuse 
perspiration and cold. Drummond's case was a boy of seven, 
who died of diabetic coma five months after receiving a blow 
on the head. 

Seegen classes children as examples of cases in which glyco- 
suria continues regardless of food. In the case which I saw, 
however, rigorous diet diminished the sugar to a trace, for a 
time, at least. 

Kiihl finds two forms of the disease, one mild or slow, and 
the other severe, both terminating fatally. The latter is found 
among the poorer classes, which receive less and later medical 
attention. 

Treatment. — Inasmuch as the chances for recovery are but 
slight, one in four at best, probably, the patient should have 
everything in his favor, and be very carefully handled, the 
urine examined frequently, and closest attention paid to every 
little detail. Children with diabetes are notoriously fond of 
sweets, and often very sly in obtaining them. If diabetic diet 
at once diminishes the quantity of sugar to a marked degree, 
great fluctuations in the quantity of sugar during supposed 
adherence to diet should suggest that the child cannot be 
trusted. 

Dr. Purdyt has called attention to the fact that not infre- 
quently the diabetic patient becomes cunning and deceitful in 
minor matters, especially those relating to his food, and quotes 
Dickinson, who says, "The mind deteriorates morally and intel- 
lectually." I think it good policy not to assume, then, that a 
diabetic child will refrain from eating forbidden sweets merely 
because he says he will. 



* Arrang'ed according to time. 
T '■'' Diabetes,'' Chicago, 1890. 



478 THE DISEASES OF CHILDREN. 

The first thing in the treatment should be gradual adoption 
of strict diabetic diet, watching its effect closely, and relaxing 
it if sudden onset of nervous symptoms occur. If not, the 
diet should be continued for several months, to be gradually 
relaxed when the maximum good effect has been reached, and 
to be begun at once again when the improvement, if any, fol- 
lowing relaxation, ceases, other things being equal. 

Dietetics, even in diabetes, is not an exact science, and must 
be used with observation both of the urine and of subjective 
symptoms. In general, however, reckless disregard of diet 
leads to rapid and unfavorable termination. 

Diet in Diabetes. — The patient should begin the diet by 
cutting off saccharine foods, candy and the like ; then in a 
week, say, potatoes ; next, desserts made of flour, together 
with sweet fruits; finally, all cake, cakes, and bread made of 
ordinary flour. It is well, I think, to cut off bread last of all ; 
moreover, if it can be proved that cutting off bread and purely 
anim.al diet do not reduce the quantity of sugar perceptibly 
after a week's trial, if necessary, then I allow a little bread, in 
quantity not to exceed two ounces daily. Finally, animal diet, 
meats, eggs, fish and gelatin, if more liberal diet fail to cause 
sugar to disappear. 

Articles Aliozved. — Clam-water. 

Fish, without flour sauce. (No oysters, and no shell-fish 
generally.) 

Meat soups, without flour or milk. 

Meats. 

Poultry, without dressing of bread or flour. 

The following vegetables only : Lettuce, spinach, cauliflower, 
cabbage, olives, water-cresses, mushrooms, asparagus tops, cu- 
cumbers. 

Eggs, poached, scrambled, soft-boiled ; carefully-made omelet. 

Cheese. 

Bread and butter, if allowed (see above), two ounces of bread 
daily, that is, one small slice morning and evening. 

Desserts: Blanc-mange, made of white of ^gg, beaten up and 
flavored with vanilla, sweetened with a little saccharin. Gelatin 
jellies sweetened with a little saccharin. 

Nuts: Almonds, hazelnuts, walnuts, cocoanuts. Brazil-nuts. 

Apples, which so many children eat so freely, are not allowed. 

The question of milk-diet is still a mooted one. Jacobi says 
that milk, skimmed or not skimmed, forms a *' principal and 
beneficial part of the diet " in diabetes in children. 

Inasmuch as cases of diabetes in young children subsisting 
entirely or chiefly on milk are, as a rule, more fatal than those 
in older ones, it is difficult to draw deductions as to benefit 



IN Die A TIONS FOR REMEDIES. 479 

from the use of milk. I should not advise it unless careful 
analyses of the urine are to be made to see whether it does not 
increase the output of sugar. In a case like that mentioned by 
Haig, where urea was deficient and uremic symptoms coming 
on, under rigid diet, I should see no objection to its use, coupled 
with relaxation of the diet. 

Waters and Beverages. — Waukesha or Bethesda ; Saratoga 
Vichy. If stimulants are necessary, whisky, gin, Budai imperial 
wine. 

Massage of the whole body is sometimes useful. It should 
not be too vigorous, and may be employed daily between 
breakfast and dinner. Schnee advises a weak solution of mer- 
curic chloride in alcohol, with a little vaseline to be used in 
rubbing. 

Electricity. — Electricity may be used in cases where there is 
great muscular weakness. 

A diet which is intermediate between the rigorous one al- 
ready advised and the ordinary mixed diet of every-day life, is 
recommended by McNutt as being, in his experience, better 
than the exclusive diet. McNutt's diet is as follows : The 
diabetic patient may eat — almond rusks, almond biscuits, gluten 
bread, gluten biscuit ; stale bread (toasted) sparingly ; bacon, 
butter, cheese, eggs, beef-tea, and thin soups; beef, mutton, 
game, and poultry ; fish, oysters ; cabbage, lettuce, string-beans, 
green peas, tomatoes, spinach, greens, olives, artichokes, as- 
paragus ; custards without sugar, jeUies unsweetened ; tea, 
coffee, cocoa without sugar ; water, mineral waters, claret, 
milk, buttermilk, acid fruits, lemons, cherries, currants, straw- 
berries, nuts. 

I have, myself, tried such a diet in several adult cases* with 
apparent benefit. 

INDICATIONS FOR REiMEDIES. 

Arsenicum takes first rank in the treatment of diabetes in 
children. Indications are as follows: loss of flesh, great 
hunger and thirst, pallor, loss of strength, tendency to gan- 
grene, dryness of the throat and mouth, watery diarrhea, 
dyspnea on slight exertion. Treatment should begin with the 
third decimal trituration, three grains, four times daily, con- 
tinued over a long period of time, the dose being gradually 
increased until one grain of the second decimal or its equiva- 
lent is given. Arsenicum should be given in the sixth deci- 
mal trituration in case aggravation occurs from the lower 



* See '' Disease of the Kidneys,'* page 383. 



480 THE DISEASES OF CHILDREN. 

potencies, preferably also in the case of very young children 
and infants. 

Lithium is undoubtedly of benefit in some cases. I have 
found it beneficial in adults and suggest a trial of it in the case 
of children. I have found nothing superior to it for relieving 
the rheumatoid pains which are sometimes very severe in con- 
nection with hyper-acid urine and uric-acid sediments. I have 
used it in adults in the form of benzoate, in doses of from J^ to 
2 grains of the chemically pure crude drug, four times daily. 
For children, the first decimal trituration might be used. Fif- 
teen- to 30-drop doses of lithiated hydrangea, so useful in 
larger doses for adults, should be thought of also. 

Salicylate of Sodium has been advocated in the treatment of 
diabetes by Jacobi, Haig, and others, given with an alkaline 
water, like vichy or seltzer. Jacobi says that a child of five can 
take 5 to 8 grains (0.32 to 0.52 grams) three times daily and 
continue its use many weeks. Haig claims that it sometimes 
increases the urea sugar ratio ; in the case of a girl of eight, dia- 
betic diet caused great fall in urea and brought on a lethargic 
condition ; she was put by Haig on mixed diet and milk, to- 
gether with 10 grains of salicylate, four times daily, and the 
ratio of urea to sugar rose. I am inclined to think, however, 
that the relaxation of the diet had much, if not all, to do with 
this matter. 

Krcasote. — Heaviness, drowsiness, depression of spirits, head 
confused and dull; very severe chronic neuralgic troubles. To 
be given in the third decimal trituration. 

Phosphoric Acid. — Of value when the case is evidently of 
nervous origin ; when there is loss of fluids ; patient is indif- 
ferent to all things ; long-lasting diarrhea. For thirst, potas- 
sium phosphate, two parts, in water 75 parts ; feaspoonful three 
times daily in a little hot tea. 

Uranium Nitrate. — Languor marked and general ; excessive 
thirst. Useful in cases originating in gastro-intestinal derange- 
ment. To be given in the third decimal. 

Jumbul. — This drug is still used extensively in adult cases. It 
is said not to be beneficial in cases where the patient is on mixed 
diet. I have no record of its value in the diabetes of children, 
but should be inclined to try it where polyuria resisting diet 
was a feature. It might be given in grain doses of the seeds 
four times daily. 

Other remedies often indicated from time to time in adult 
cases, and hence not to be forgotten in children, are bryonia, 
lactic acid, leptandra, podophyllum, aurum muriaticum, nitric 
acid, mercurius solubiiis, graphites.* 

*See Mitchell's " Diseases of the Kidneys," 2d edition. 



NOTES ON TREATMENT. 481 

MISCELLANEOUS NOTES ON TREATMENT. 

Stern, who has seen a large number of cases in children, relies 
chiefly on dietetic treatment. Next to this he advocates the 
diet and bath at such places as Neuenahr, Carlsbad, and Vichy. 
Alkaline bicarbonates are the best drugs, though none are spe- 
cially curative. 

Schnee claims to have cured four children, ages nine to thir- 
teen years, one of his cases still showing no sugar five years 
after cure. His treatment was Carlsbad water, Turkish baths, 
internal remedies, and massage of the whole body. In the case 
of a girl of nine, cure was brought about by the use of Carlsbad 
water for two months in conjunction with Russian baths and 
wet-sheet packings, massage of the whole body and internal 
medicines. He does not name the latter, but in another part 
of his work praises Bamberger's formula for corrosive sublimate- 
albuminate and potassium bichromate, using these remedies 
both internally and externally by massage. 

Treatment of Diabetic Coma. — Preventive treatment, if pos- 
sible, is the only one. Fatigue, especially that from travel, is 
to be guarded against ; diet relaxed, and the bowels opened 
with castor oil. When patient begins to be drowsy and to have 
pains in the stomach, give hot bath and make hot applications 
to extremities. Try also sodium bicarbonate in lO-grain doses 
hourly. 

Reports of Cases. — Inasmuch as diabetes in children has 
hardly received merited attention, it will not, I hope, be out 
of order to quote reports of the following cases found in the 
journals: 

Dr. J. S. Thatcher exhibited a specimen of blood removed 
from a girl fifteen years of age, in the service of Dr. Beverly 
Robinson at St. Luke's Hospital. ''About four or five months 
before her death she began to lose flesh and strength, and to 
suffer from great thirst. During the three months she was in 
the hospital the urine contained no albumin, and the daily 
average of sugar was from four to six per cent. She gained in 
weight slightly immediately after admission, but afterwards 
lost flesh steadily. The day before her death she was up and 
around the ward ; about ten hours before death she was found 
to be cold, and suffering from labored breathing, and three hours 
later, after a dose of morphin, she was found asleep, with a 
pulse of 130, and respirations 16 and very deep. About six 
hours before death she was seized with a tonic spasm, which 
lasted for about ten minutes, and was succeeded by coma which 
continued until her death. All the vessels in which any blood 
was found contained blood of white color, or of the pinkish 
D. C— 31 



482 THE DISEASES OF CHILDREN. 

hue shown in the specimen. In the heart there were some 
reddish coagula and a quantity of blood looking like coagulated 
milk. The occurrence of dyspnea is interesting in connection 
with this fatty condition of the blood."* 

In a clipping which I have found from the Therapeutic 
Gazette, in which the name of the writer has been unfortu- 
nately torn off, occurs an account of the following case : 

" This case at the Chelsea Infirmary was kindly placed un- 
der the treatment by Mr. Moore. It was of the so-called pan- 
creatic type. A boy, aged thirteen, whose father had recently 
died of diabetes, had suffered from symptoms of diabetes, be- 
fore beginning this treatment, for six months. From January 
I, 1892, he was placed on diabetic diet, and Avas given first 
codein, from which he received no benefit, and then morphin, 
under which he improved. The zymin treatment, with diet as 
before, was begun May 18. His general condition was bad; 
appetite not ravenous ; thirst great ; weight, five stone, ten and 
three-quarter pounds ; quantity of urine in twenty-four hours 
about 99 ounces; specific gravity, 1036 ; sugar estimated at 6.5 
grains per ounce. Zymin was given in increasing doses, with 
the subsequent addition of sodium bicarbonate, and finally 
pancreatin pills, coated with keratin, were substituted. A 
daily record of the amount and specific gravity of the urine 
was kept, and quantitative estimates of sugar were made with 
Fehling's solution. The treatment was continued till August 
21, when he left the infirmary. Unfortunately, owing to decep- 
tion on the part of the patient, and dietetic indiscretions, which 
caused diarrhea on more than one occasion, many of the obser- 
vations are valueless, and with the amount of comment neces- 
sary would be out of place in this summary. What is certain 
is, that his general condition vastly improved, his weight in- 
creased jY^ ounces and thirst diminished. During the first 
ten days of treatment the amount of urine in twenty-four hours 
averaged 78 ounces, and for the last ten days before leaving it 
averaged 35 ounces, while the specific gravity for the same 
periods averaged 1036 and 1027 respectively. The first reliable 
quantitative estimation of sugar, made May 20, gave 6.5 grains 
to the ounce; the last, made at the end of June, 4.5 grains. 
The boy was re-admitted November 5, and is still in the in- 
firmary. He is improving under opium, but has not reached 
the standard of last summer under the pancreatic treatment. 

** No definite deduction can be made from this case, owing to 
the facts, already mentioned, that he was improving at the 
time zymin was commenced, and the intractability of the 



=■= Medical Record. 



NOTES ON TREATMENT. 483 

patient, while the summer weather and the continuance of 
restricted diet were in his favor." 

Dr. W. D. Hamaker^ reports the following case : 

E. H., female, white, aged fifteen years; consulted me No- 
vember 7, 1887, with the following history: She had the ordi- 
nary diseases of childhood ; had had scarlet fever when two 
years old. No history of rheumatism nor of any fright or 
shock. She began to menstruate in June last; menses scanty 
and pale. No disease could be discovered on the father's or 
mother's side, except that one aunt had chorea. 

In July she failed in health, and about two months before 
coming to me, she began to have a ravenous appetite, with loss 
of flesh, great thirst and increased amount of urine. These 
increased rapidly, and on November 7 she presented great 
emaciation, pale skin, dry, fissured tongue and hay-like odor of 
breath. 

November 8. — She weighed 87 pounds, and the amount of 
urine in twenty-four hours was 36 pints, with a specific gravity 
of 1028, and giving a strong reaction with Fehling's solution. 
She was also troubled with pruritus vulvae. I put her on 1-24 
grain of strychnin and 3 grains of ergotin t. d., and a strict 
diabetic diet. 

November 14. — Urine diminished to 12 pints, with specific 
gravity of 1026. Was able to keep her on the diet very easily. 
Thirst was much diminished. 

November 21. — Put her on three grains of carbonate of lith- 
ium and i-io grain of arseniate of sodium per diem, dissolved 
in a quart of water. This is to be drunk at meal time. No 
other medicine was given, and the diet was continued as before. 
Not much liquid allowed, except a couple of glasses of milk 
and the water taken with the medicine. 

November 28. — Amount of urine per diem 11 to 12 pints in 
the last week; weight 86 pounds; feels much better; thirst 
not marked; no pruritus. A large alveolar abscess opened to- 
day. General appearance of patient much improved. 

November 29. — Last night was the first night in which she 
was not compelled to rise to urinate. 

December i. — Weight 87 pounds. 

December 3. — Arseniate of soda continued at i-io grain 
per diem, but the lithium carbonate increased to 12 grains per 
diem. 

December 8. — Medicine and diet continued as before. Patient 
feels better and looks better ; drinks very little. 

December 13. — Reduced liquids to one pint of water with the 



* Therapeutic Gazette. 



484 THE DISEASES OF CHILDREN. 

medicine. Allow no tea, coffee, apples or oranges, and as little 
water or milk as possible ; weight Z'j pounds. 

December 20. — Strong and bright ; specific gravity of urine, 
1028. From November 28 to present date the amount daily 
has been from 9 to 12 pints. 

December 24. — Quantitative analysis showed 22 grains of 
sugar to the ounce. This was the only quantitative analysis 
made. 

January 2. — Weight 87 pounds; specific gravity 1022; gen- 
eral health improving. Patient has adhered strictly to diet 
and the treatment continued as before. A small piece of well- 
done toast was allowed twice a day, but immediately the urine 
increased in amount. The toast was stopped at once. 

January 8. — The daily amount of urine continues at 10 to 12 
pints ; specific gravity, 1022. Apparently she was doing as 
well as before. 

I did not see the patient again till January 16, when I found 
her almost comatose, with labored breathing; tongue and lips 
dry and parched ; some pain in the chest and great deafness ; 
specific gravity of urine, 1015 ; and strong reaction was shown 
on testing for acetone. Death ensued the following day. 

In this case the new treatment was faithfully carried out in 
every detail for eight weeks, and until one week before her 
death there was apparent improvement ; but the sudden change, 
the onset of coma, the presence of acetone and the other symp- 
toms showed no difference from the termination of cases treated 
by the old methods. 

My next case I shall treat in the same way ; for we should 
give a fair trial, in so intractable a disease, to any method 
which promises to be successful in even a few cases. 

Dr. F. C. Simpson reports the following :* 

** John S. ; boy three and a-half years old ; parents living and 
healthy ; neither parent showing any hereditary taint as to 
diabetes. I saw him on October 23, 1891 ; he seemed to be 
well-nourished and what I would call a fairly healthy boy. I 
gleaned from the parents the following history : 

" The boy had for the past three weeks showed decided 
muscular weakness, increased urination and quite a thirst, 
drinking quite a quantity of water during the twenty-four 
hours. He also had a partial loss of appetite, which is contrary 
to the habit in the majority of these attacks. He was very 
fond of sweet things, and was allowed to eat freely of these, 
such as preserves, candy, etc. Upon inquiry, his mother 
thought that he must have passed about three and one-half 



* American Practitioner and News. 



NOTES ON TREATMENT. 485 

pints to four pints of urine in twenty-four hours. He asked 
for water while I was examining him, and drank off a glass 
without stopping. I asked for a sample of his urine, which 
was sent me the next morning, the first he had passed after 
getting out of bed. Test of urine : Color, straw ; reaction, 
alkaline; specific gravity, 1040. Upon adding the urine to 
Fehling's solution under heat, it turned a yellow color, which 
was at once precipitated to a copper-red, showing conclusively 
that sugar was present. I afterwards had a quantitative test 
made, and the report was about three grains of sugar to the 
ounce. At this time the boy's parents gave another chapter in 
the history, in which it was brought out that the little fellow 
had fallen down stairs (about fifteen or twenty steps) just be- 
fore the time that they had noticed the symptoms detailed 
above. In the fall the boy did not become unconscious, and 
there was nothing more than a scare. He did not complain 
of any pain about the head ; in fact, he seemed to be all right 
in a few minutes, and never showed any signs of after-effect. 

"■ I made another examination of his urine at the end of a 
week, and found there was a slight decrease in all his symptoms 
and not as much sugar ; specific gravity, 1030. His mother 
said he did not show as much thirst, and the quantity passed 
was only three pints during the twenty-four hours. I had in- 
structed her carefully to measure each quantity passed. I saw 
the child at the end of two weeks, and a sample of his urine 
showed a specific gravity of 1024. Fehling's test showed sugar 
in very small quantity. I had a quantity test made, and it 
showed only one grain to the ounce. His general health was 
greatly improved ; thirst was not as great, and the quantity of 
urine was only two pints in the twenty-four hours. 

"■ The treatment was ergot and bicarbonates, and this was 
the only treatment he received during the three weeks. He 
has continued to improve from the beginning of treatment, and 
at the end of four weeks the urine is normal. His general 
health is greatly improved, and I have made examinations of 
his urine every week, and found nothing abnormal. I consider 
the boy cured of his diabetes." 

The following questions may be pertinently asked : What 
was the cause of this glycosuria? Was it due to injury of the 
brain induced by the fall, or was it due to the causes that pro- 
duce diabetes we so frequently see in the adult? The nervous 
element was the predisposing cause, and the shock had some- 
thing to do with producing the saccharine urine. 

Leva saw a case in a girl of twelve, of healthy parents, nine 
months ill. It began without known cause, with intense thirst, 
rapid emaciation, cramps in the calves, and soon intense 



486 THE DISEASES OF CHILDREN. 

glycosuria, polyphagia, polydipsia, polyuria, and malaise. On 
the fifth day after treatment was begun coma set in, and death 
followed in two days. Autopsy showed atrophied heart, ate- 
lectasis of deep portions of the lungs, slight enlargement of the 
spleen, enlarged kidneys, and milky condition of the blood. 

Shaffer reports a case of a boy of fourteen years, who had never 
been ill until on a certain date (December 27) he was thirsty 
and passed much water at night. On January 4 he went skat- 
ing. On January 5 he had dyspepsia, constipation, excessive 
micturition, and thirst. On the 8th there was labored respira- 
tion, mostly thoracic, with decided hebetude. On the 9th, at 
midnight, he was moribund, but rallied under stimulants and 
external applications. Temperature, 96° to 98°. He became 
comatose at 10:30 A. M., and died. 

Watkins-Pitchford reports a case in a boy eight years and 
nine months old, who, for a fortnight, had had dry mouth and 
throat ; polyuria ; urine, 1035 in specific gravity ; no albumin, 
but sugar present. The pulse was 80 and strong. A few days 
after, being placed on diabetic diet, respirations doubled in fre- 
quency, but there were no physical signs. He vomited once or 
twice at intervals of a few hours, and the temperature was sub- 
normal. He died on the following day. During the twenty- 
four hours prior to death he passed 16 ounces of urine, of a 
specific gravity of 1040, strongly acid, plenty of sugar and ^ 
albumin. His mother had died, eighteen days previous to the 
beginning of the boy's illness, of phthisis pulmonalis. 

Dr. C. W. Purdy reports the following case : 

Case 223. — B. G., December 31, 1888. Patient's age four 
years and three months. His mother first noticed, in August 
last, that he was urinating very frequently, " wetting the bed " 
at night. About the same time he became very thirsty. He 
has recently lost considerably in weight. He complains of be- 
ing weak and tired much of the time. His mother states that 
he urinates about every half-hour. Careful inquiry fails to re- 
veal any history of diabetes in the family, but tuberculosis is 
prominent. The patient has had no serious illness before, but 
he fell upon the floor of a car a short time before his present 
illness began, and sustained a severe blow upon his head. His 
urine to-day is clear ; color, light greenish-yellow ; acid reaction ; 
specific gravity, 1033 ; and contains 20 grains of sugar to the 
ounce. The urine is free from albumin. The patient was 
ordered a diet of milk, meats, a little cracker, and some green 
vegetables. No medicines were prescribed. 

January I, 1889. — Urine to-day : specific gravity, 1025 ; sugar, 
12 grains to the ounce. 



NOTES ON TREATMENT. 487 

'February \. — Urine: specific gravity, 1030; sugar, 10 grains 
tothe ounce, no albumin ; diuresis and thirst greatly dimin- 
ished ; he gives his nurse no more trouble at night from calls 
to urinate. The family physician now volunteered to cure the 
patient, and, as my prognosis was such as to afford the parents 
no hopes of recovery, the patient passed into the hands of the 
more sanguine physician. 

October 14, 1889. — The parents of the child returned and re- 
quested me to resume treatment of the case. Examination of 
the patient showed extreme emaciation, great thirst, and diu- 
resis. The patient had been permitted a mixed diet, including 
all fruits and farinaceae, and, as a consequence, the disease had 
progressed at a rapid pace. Examination of the urine resulted 
as follows : color light ; reaction acid ; specific gravity 1038 ; 
sugar present, 25 grains to the ounce; urea, .013 gram to the 
cubic centimetre of urine (13 grams per litre, 6 grains per 
fluidounce) ; phosphates greatly in excess ; the urine is free 
from albumin ; the patient seems tired, weak, restless, and has 
little or no appetite. He was put on milk with a little bread, 
and quinin was ordered in i-grain doses three times a day. 

October 18. — The appetite has somewhat improved, and the 
patient seems less weak. The urine to-day is clear ; acid in re- 
action ; specific gravity, 1033, and contains 25 grains of sugar 
to the ounce ; phosphates greatly in excess ; no albumin pres- 
ent ; diet to be restricted almost entirely to milk ; to continue 
quinin, 3 grains daily. 

October 21. — Urine, 4 pints; specific gravity, 1029; sugar, 
18 grains to the ounce. To continue treatment as before. 

October 28. — The patient seems very weak ; has little or no 
appetite. Urine to-day : specific gravity, 1033 ; sugar, 16 
grains to the ounce ; phosphates in excess ; no albumin present. 

November 4. — Urine to-day; specific gravity, 1029; clear; 
acid reaction; sugar present, 12 grains to the ounce; phos- 
phates in excess. To continue milk diet, with very little bread, 
and some green vegetables. 

November 12. — Urine : specific gravity, 1024 ; acid reaction ; 
sugar, 10 grains to the ounce. The patient is weak ; has little 
relish for food, and is troubled with slight cough. 

November 24. — The cough is better, and, on the whole, the 
patient seems somewhat stronger. Urine, 5 pints ; specific 
gravity, 1028 ; sugar, 10 grains to the ounce ; no albumin. 

December 6. — Urine is clear ; color light ; specific gravity, 
1033 ; sugar, 10 grains to the ounce. 

December 18. — Patient began to complain of pains in his 
stomach and bowels, and to grow a little drowsy to-day. His 
respirations were somewhat quickened. He was given a hot 



488 THE DISEASES OF CHILDREN, 

bath, and hot bottles were applied to his extremities, and lo- 
grain doses of sodium bicarbonate were ordered every hour. 

December 19. — Patient is more stupid to-day ; sleeps much of 
the time. The respirations have increased in frequency to 40 
per minute; the temperature is 101° Fahr. The abdominal 
pains have subsided. Toward evening the patient became more 
stupid and refused all food. 

December 20. — Patient died to-day in a comatose state, with-^ 
out convulsions. 



CHAPTER IX. 

DIABETES INSIPIDUS. 

Definition, — Diabetes insipidus is a disease characterized by 
persistent polyuria, without presence of sugar or albumin in the 
urine, and usually accompanied by polydipsia. 

Etiology. — The disease is common in childhood. Some cases 
are hereditary in origin ; others probably due to brain lesions, 
syphilitic and otherwise. Inveterate masturbation, inconti- 
nence of urine, or tapeworm were the only exciting causes as- 
certained in some cases. Cases are said to originate from 
trauma, especially to the head, or febrile attacks. Violent mus- 
cular effort and violent mental emotions are said to cause it. It 
occurs in tubercular meningitis, epilepsy, and hereditary syph- 
ilis, and as sequela to acute infectious diseases. It has in some 
instances been apparently traced to parents allowing young 
children to drink alcoholic liquors. Exposure to cold, and 
drinking cold fluids when heated, and exposure to hot sun 
seem to have been exciting causes in a few cases. Abuse of 
diuretics has been mentioned as an exciting cause. Johanne- 
sen reports a case in an infant apparently due to the bite of a 
wood-beetle. In many cases the etiology cannot be deter- 
mined. In general the disease is thought to be a neurosis 
having its origin in the dilatation of the renal arteries, from 
paralysis or irritation of their vaso-motor nerves. 

Age. — Out of 70 cases mentioned by Roberts, 7 were in- 
fants ; 15 from five to ten years old ; 13 from ten to twenty, 
and the rest from twenty to seventy, only 4 being from fifty 
to seventy. In other words, fifty per cent, of the cases were 
under twenty years of age, and not quite fifty per cent, between 
twenty and fifty. 

PatJiology. — The disorder has no fixed pathology. The kid- 
neys are oftener diseased than in diabetes mellitus, but in some 
cases were apparently normal. In many instances lesions in 
the flow of the fourth ventricle, as in diabetes mellitus, have 
been found. 

In some of the most acute cases, when emaciation and debil- 
ity were great, and polyuria excessive, no pathological condi- 
tions could be found after death sufficient to account for the 
symptoms. 

(489) 



490 THE DISEASES OF CHILDREN. 

Symptoms. — In some cases polyuria, which maybe excessive, 
is the only symptom. 

Other symptoms than polyuria most commonly seen are the 
following : Dry, harsh, hot skin ; dry mouth and throat ; emacia- 
tion, thirst, which may be intense ; loss of strength ; neuralgic 
and rheumatic pains. In cases where the amount of solids in 
the urine is small (hydruria), the patient feels poorly, is easily 
chilled, appetite is capricious and there is a sinking, gnawing 
sensation in the pit of the stomach. In cases where the total 
quantity of normal solids voided in the urine is large (polyuria), 
there are severer symptoms, as above noted. 

When cerebral lesions are present, disturbances of sensibility 
or of motion are present. Headache or convulsions may occur. 
Ptyalism has been noticed in several cases. 

Cases are known in which excessive elimination of phosphoric 
acid occurs. In these cases, although sugar is absent, there is, 
in addition to the symptoms mentioned above, a tendency to 
boils, ravenous appetite, possibly cataract, as in the case of dia- 
betes mellitus. This kind of diabetes insipidus is called phos- 
phatic diabetes, and is associated sometimes with nervous 
derangements or with phthisis, sometimes with neither. Again, 
in some cases excessive elimination of the chlorides may be 
noticed (chlorine diabetes). 



THE URINE IN DIABETES INSIPIDUS. 

We find two forms of this disorder, namely, hydruria and 
polyuria. In hydruria the quantity of urine per twenty-four 
hours is enormous and the specific gravity below 1008. In 
polyuria the quantity of urine, though not enormous, is greatly 
increased, and the specific gravity loio and upwards. 

The total urine per twenty-four hours is usually that of fluids 
ingested ; but if the fluids be cut off, the urine is not diminished 
proportionately. The volume of urine per twenty-four hours 
is generally greater than that of diabetes mellitus. Very young 
children have been known to void as much as 30 pints in the 
twenty-four hours. Roberts speaks of a girl of ten who voided a 
little more than a third of her own weight of urine. Ten to 15 
pints daily (5000 to 7500 c. c.) is not uncommon in the case of 
children afflicted with this disease. 

The total solids are as a rule above normal per twenty-four 
hours though decreased relatively (grains per ounce, grams 
per litre.) 

In some cases, without great increase in twenty-four hours' 
urine, the total phosphoric acid is double or treble the normal 



URINE IN DIABETES INSIPIDUS. 491 

per twenty-four hours (phosphatic diabetes), and the urea phos- 
phoric-acid ratio diminished. 

Peptone and hippuric acid are occasionally found. 

The urine is usually feebly acid, undergoes alkaline change 
readily, and then deposits a white, creamy sediment of simple 
phosphates. The color is from pale-yellow to light-yellow and 
the odor deficient. When freshly voided, it is clear like water, 
but soon becomes cloudy from presence of micro-organisms. 
The sediment is very scanty in the freshly-voided urine, and 
usually contains nothing of significance. 

I am convinced that the ordinary com.putation of total solids 
by Trapp's co-efificient is worthless in some of these cases, 
especially in hydruria. 

Analysis of CJiildren s Urme. — Grancher reports a case in a 
child (sex not mentioned) of eight, in which the etiology was a 
blow on the left temple. The twenty-four hours' urine was 14 
to 16 pints (7 to 8 litres); the specific gravity, 1003 to IC04; 
urea 1.2 grams per litre (0.5 grains per fluidounce) ; urea, total, 
less than 10 grams (155 grains) in twenty-four hours. Chlorides 
were 0.7 gram (11 grains), phosphates o.io gram (i 1-2 grains) 
in twenty-four hours. 

This, then, is an example of the first class of cases mentioned 
above, namely, simple hydruria. Now the total solids in this 
case computed by Trapp's co-efficient would be 4x2x7, or 56 
grams, manifestly an absurdity, as the total urea, chlorides, and 
phosphates all together, were less than 1 1 grams, and it is not 
likely that the remaining constituents, sulphates, creatinin, etc., 
would amount to 45 grams. 

Course and Prognosis. — The duration of the malady is uncer- 
tain. Congenital cases may last fifty to sixty years. Cases 
which recover usually do so in one or two years, though recov- 
ery in a longer time is not impossible. Cases beginning sud- 
denly and those due to blows, run a most acute course, and may 
die within a few months, though Guinon, differing from other 
authorities, regards cases due to trauma, as well as those de- 
pendent on febrile attacks, as especially curable. Those begin- 
ning in youth without known cause are regarded favorably 
from the standpoint of prognosis. 

In some cases the patient lives for years in comparatively 
good health, succumbing possibly to phthisis, pleuro-pneu- 
monia, or organic disease of the brain, since diabetes insipidus 
is seldom fatal by its own virulence. 

Owing to the contradictory testim.ony of the different author- 
ities, and the absence of pathological information, we must 
form our opinion from the general condition of the urine. If 
the urea and phosphoric acid are not largely in excess of normal, 



492 THE DISEASES OF CHILDREN. 

the patient being well cared for and without hereditary taint, 
it is possible that he may live as long as otherwise. If, on the 
other hand, there is marked increase of urea and phosphoric acid, 
suspect the condition to be but a prelude to serious constitu- 
tional disturbance, and give ultimately unfavorable prognosis. 
In some cases nervous disorder or phthisis appears ; in others, 
diabetes mellitus. Albuminuria is an unfavorable sign, as is 
also edema of the feet. In one case which I saw, apparently 
congenital, at the age of sixteen I found albumin ; two years 
later casts appeared, the patient became more or less edema- 
tous, and died of uremia. Children may succumb to exhaustion 
caused by loss of rest, tormenting thirst, and mental worry. 

TreaUnejit. — Everything which aggravates the condition 
must be sought for, and if possible removed ; inveterate mas- 
turbation, enuresis, even tapeworm, hereditary syphilis, must 
not be overlooked. Phimosis and rectal diseases should receive 
attention. 

When the patient is not voiding too much urea, give food 
and drink liberally, seeing to it that drinks are not too cold. 
The various drinks may be thickened, as, for example, by the 
use of a handful of raw oatmeal to a quart of boiling water with 
a lemon sliced into it. Warm woolens should be worn, and the 
patient, if possible, spend winters in a warm, dry climate. Salt- 
water douches are sometimes useful in promoting bodily vigor. 
Warm baths, followed by friction of the skin with coarse towels, 
are beneficial. 

In cases where urea is increased relatively to the weight of 
the patient, nitrogenous food is to be limited. Alcoholic drinks 
and coffee not allowed. Vapor baths, followed by salt-water 
tepid douches, are recommended and a dry, bracing climate 
sought. Hygienic care and regulations, as in diabetes mellitus, 
ordinary warm baths, followed by friction of the skin with 
coarse towels, are often found beneficial. 

Remedies. — Those already mentioned under diabetes mellitus 
are frequently indicated in this disorder. 

In anemia and debility, ferrum, nux vomica, and china; 
cod-liver oil and the iodide of iron will help debilitated children 
with diabetes insipidus. In syphilitic cases, iodide of sodium. 

Jumbiil will undoubtedly, in some cases, decrease the quan- 
tity of urine ; but its action is at best but imperfectly under- 
stood, and it is said not to be efificacious with the patient on 
a mixed diet. 

Heleiiiii will be indicated in some cases. 

Apocyiiiim is said to be useful for the well-known *' sinking 
sensation " at the stomach. 

Strychnia, in one-grain doses of the third decimal trituration, 



URINE IN DIABETES INSIPIDUS. 493 

possibly increased in time to the second decimal, is of use in 
combating the various nervous symptoms. 

Sodium brornide is believed by Purdy to have arrested two 
cases ; he thinks that the drug should be given in doses large 
enough to affect locomotion, and then decreased to a point just 
short of affecting it. In some cases the constant galvanic cur- 
rent has been found beneficial. Purdy says that the best 
results are said to follow the application of the positive pole to 
the cervical region over the vertebra, and the negative pole to 
the lumbar region and pit of the stomach, alternately. 

Ergot appears to have cured some cases. The doses recom- 
mended are 60 to 120 minims of the fluid extract for an adult. 

Miscellaneous, — Claims are made by the older school of cures 
by the following agents : Potassium iodide and mercury (dose 
not given) reduced the urine of a child of six from 30 pints to 
4 (Demme) ; combined use of antipyrin, 0.5 gram (7^ grains) 
three times daily, powdered valerian root three times daily, 
and galvanism to the cervical sympathetic and to the spine, 
cured a case in a boy of twelve years, who voided 13700 c. c. 
in twenty-four hours, with specific gravity less than looi 
(Zeuner). 



CHAPTER X. 

ENURESIS. 

Definition and Synonyms. — Involuntary emission of urine; 
incontinence of urine. Enuresis nocturna, incontinence of 
urine at night; enuresis diurna, incontinence of urine during 
the day; enuresis continua, incontinence of urine both during 
day and at night. 

Etiology and Pathology. — In a large number of cases the cause 
is persistence of infantile weakness in the neck of the bladder — 
incompetence of the sphincter. In another series of cases, in- 
creased reflex irritability of the bladder is the cause, compli- 
cated or uncomplicated with the above described incompetency 
of the sphincter, and depending either on the bladderitself ordue 
to some outside cause (Jacobi). Some of these causes of irri- 
tability are as follows : fissure of the neck of the bladder, vesi- 
cal calculus ; increased irritability of the bladder from unknown 
cause ; increased quantity of urine, as in diabetes, nephritis, or 
from increased ingestion of water; irritant nature of the urine 
from hyperacidity, hyperalkalinity, or drugs, including salines, 
chlorides, and chlorates ; anal irritation from pin-worms, fissure, 
eczema, etc. ; hyperesthetic state of the external genitals de- 
pendent on stricture, phimosis, balanitis, etc. ; the psychical 
influence of dream impression. Unconscious micturition may 
also be due to general debility, spinal disease, injuries and dis- 
eases of the spinal cord, diseases of the vesical nervous supply, 
and acute febrile diseases. In some cases the complication of 
enuresis with general muscular insufficiency is very marked. 
Masturbation is said in the young to lead to chronic inflamma- 
tion of the whole prostatic portion and the neck of the bladder, 
which is then very sensitive ; hence incontinence of urine may 
sometimes be due to this habit. Cystitis adds to the irritabil- 
ity of the detrusor muscles and is a frequent cause of inconti- 
nence, when this makes its appearance in children whose 
micturition was normal before (Jacobi). 

Pyelitis and vaginal catarrh are also to be included in the 
etiology. 

Taylor's classification of the causes of enuresis is as follows : 
mechanical, diathetic, reflex. 

Mechanical Qd^usQs are adherent folds of mucous membrane 
(494) 



EA^URESIS. 495 

in and about the genitals ; mechanical irritation of foreign 
bodies, as seat-worms. Small polypoid excrescences at the 
neck of the bladder in very young girls have been found by 
Jacobi. 

Diathetic causes: Uricemia is often found after over-fatigue 
in play or excitement, or manifested by tonsilitis or several 
forms of pharyngeal irritation, or by sediment of uric acid in 
the urine. Phosphatic urine or urine alkaline from fixed alka- 
lies is to be reckoned among these causes. 

Reflex causes may be a combination of mechanical and 
diathetic, or a result of emotion, habits, instability of nervous 
balance. 

Slight palsies should be searched for. Taylor believes that 
enuresis is often found in children in whom slight hemiplegias 
with descending degenerations had occurred. 

Insufificient innervation, as in the case of slow, dull, stupid 
children, is a cause. 

Mouth-breathing children may have incontinence due to slow 
carbonic-acid poisoning. 

Krauss divides the causes of enuresis into four groups : First, 
functional disturbances of the genito-urinary organs causing 
irritation, as tight prepuce, irritable clitoris, narrow meatus, 
sensitive urethra, weak sphincter, cystitis, due to pressure on 
bladder in pregnancy, and ascarides in the rectum ; second, 
cerebral nervous disorders, precocious and pernicious mental 
development, and dreams ; third, failure of spinal reflex, as in 
locomotor-ataxia, transverse myelitis, tumors of the cord ; fourth, 
organic changes in the genito-urinary tract. 

Van Tienhoven believes the exciting cause of nocturnal enu- 
resis in boys to be the incomplete closure of the prostatic 
urethra, during the general muscular relaxation of sleep. The 
urine collecting in the bladder soon finds its way into the 
urethral pouch and gives rise by its presence to reflex detrusor 
spasm. 

Kupke thinks it possible that incontinence is often the result 
of a weakness on the part of the spinal cord, which loses its 
power to transmit to the brain the impression of distention in 
the bladder. On the other hand, we must admit that an anes- 
thetic condition of the sensitive nerves of the bladder can 
occur, by reason of which the micturition center in the spinal 
cord is only feebly made aware of the need to urinate. Weak- 
ness of the bladder, from general debility or anemia, is a very 
common cause ; the bladder, not being able to tolerate any 
quantity of urine, readily excites the motor apparatus. A case 
of the kind has been known to follow typhoid fever. 

Hysterical children may have nocturnal incontinence. Ac- 



496 THE DISEASES OF CHILDREN. 

cording to Trousseau, the first cause of incontinence is a neu- 
ropathic disposition. If periodicity of incontinence is a marked 
element in it, then the condition is nervous in origin. 

Incontinence may accompany severe nocturnal epilepsy and 
in all obscure cases possibility of the latter should not be over- 
looked. It also may accompany night terrors. 

Bobulescu saw two cases, four and five years old respectively, 
in which the incontinence was dependent upon splenic hyper- 
trophy. 

It is now held that certain cases of incontinence in boys dis- 
appear with growth and development of the prostate, which is 
properly a muscle and not a gland. 

Diurnal. — Incontinence of children is thought by some au- 
thors to depend on inordinate and uncontrollable contraction 
of the bladder, hence, sometimes denominated chorea of the 
bladder. Oberlander thinks it due only to reflex irritation in 
the urethral and anal openings. Fauboren says the cause is in- 
sufficiency of the sphincter vesica, which permits a little urine to 
enter the upper portion of the urethra, and its presence there 
causes a further performance of the act by the excitation of re- 
flex contraction. Enuresis is attributed by some to a lack of 
power of retention, and enfeeblement of the voluntary power 
of the sphincter at the neck of the bladder and commencement 
of the urethra. 

Bissell thinks daytime enuresis due most commonly to some 
constitutional or general cause. It is found in children who are 
bright, cheerful, active, hypersensitive, or dull, stupid, and 
slow in mind and muscles. It may also be due to some local 
disturbance or irritation, or phimosis, worms in the vulva, va- 
gina or rectum, inflammation of bladder and urethra, stone, 
growths, etc. 

EXAMINATION OF PATIENT. 

1. Examine the rectum ; look for pin-worms, fissure, eczema. 
Inquire whether constipation is present or not. 

2. Examine the external genitals ; look for phimosis, adher- 
ent folds of mucous membrane in and about the genitals, sen- 
sitive clitoris, tight prepuce, narrow meatus; hypersensitive 
condition of the vagina, vestibule and urethra in girls, points 
to masturbation as a cause ;* enlarged penis and scrotum in boys, 
together with general malaise, dull headaches, alteration of 
temper and somnolence, are due to same cause. It is needless 
to say, however, that catching the child in the act is the surest 



*See also article on " Diagnosis of Masturbation.' 



ENURESIS— EXAMINATION OF PATIENT. 497 

means for diagnosis of this habit. Look for balanitis, vulvitis, 
stricture of the urethra, urethritis, sensitive urethra, excres- 
cences about the meatus urinarius in girls. Vaginal catarrh 
must not be forgotten. Possibility of retention in the bladder 
should not be overlooked. 

3. In case nothing be found by examination as above, collect 
■:he twenty-four hours' urine, examine it, and also a freshly- 
voided specimen ; the night urine may be saved either by the 
devices already mentioned in case of young children, or by use 
of a rubber urinal in older ones. 

The points to be sought for in the examination of urine are 
presence of cystitis, pyelitis, nephritis, or diabetes ; or, if these 
are absent, effort should be made to ascertain whether or not 
there is increased acidity, whether uric-acid crystals, calcic oxa- 
late, triple phosphate, or even simple phosphates (earthy) are 
present. 

4. If the condition of the urine shows nothing, look for mal- 
formations of the urethra and bladder, and for stone in the 
bladder. 

5. Still further, if nothing thus far has been found as a cause, 
consider muscular weakness of the bladder due to general de- 
bility, anemia ; inquire for history of recent severe illness, as 
typhoid. Investigate the possibility of spinal disease, and look 
carefully for slight palsies. Nocturnal epilepsy must not be 
forgotten, and mouth-breathing looked after. 

6. Even if no signs of uricemia be present in the urine, ex- 
amine patient for presence of tonsilitis or pharyngeal irritation, 
and if found, examine urine frequently for evidences of urice- 
mia, especially that voided after over-fatigue at play. 

7. Next inquire for psychical causes ; ask the child if he 
dreams that he wants to urinate, or that he is urinating. Ob- 
serve whether the child is intensely somnolent, unbalanced, etc., 
etc. Ascertain \^\i^\\s.^r periodicity of incontinence is a marked 
feature ; if so, the case is of nervous origin. 

Treatment. — Enuresis dependent upon the conditions enu- 
merated one to five, will yield only to successful treatment of 
the disorders to which it is secondary. Rectal diseases re- 
quire attention from an orificialist. In cases due to phimosis, 
circumcision, as an extreme measure and only when absolutely 
necessary, should be performed when the prepuce is adherent ; 
it is generally sufificient to break up the adhesions by stretch- 
ing the prepuce and removing the smegma. 

Taylor describes his method of stripping adhesions as follows : 

" I take a blunt-pointed probe, or similar instrument, and 

cautiously run it around over the head of the glans from the 

frenum on one side, by small circular motions, to the frenum on 

D.C.— 32 



498 THE DISEASES OF CHILDREN. 

the Other, and then advancing the point of the probe again ro- 
tate back to the first point to the right, and then over to the 
left, until gradually I have broken up the adhesions under the 
foreskin, and then, when this is done, I introduce into the cav- 
ity thus formed some lubricant, and make sure of its proper 
distribution. Afterwards the foreskin may be gently retracted ; 
but if the opening be small, I postpone this for a day or two, 
when, again running the probe back and forth over the glans, 
very likely the foreskin can be retracted. Failing, I wait a few 
days longer, and if the os still be very constricted, I gently 
stretch it by some suitable instrument, as a pair of dressing for- 
ceps, and thus gradually secure my purpose. The mother is 
carefully instructed to wait a certain length of time after my ma- 
nipulations, and then herself to retract, wash, and reanoint the 
parts ; to be done at intervals of two or three days. A more 
rapid stripping may be safely done, but in the manner described 
everything needed is usually accomplished, and with the mini- 
mum of pain and discomfort to the child and of alarm to the 
mother, always an important consideration. 

*' In little girls, irritations about the vagina must be looked 
for in the same way, although occurring less frequently. The 
prepuce of the clitoris is not seldom adherent, just as occurs in 
boys. The process of relieving it is very much easier in the 
girls, however, and yet of quite equal importance. It may 
sometimes be necessary in these procedures to use a little co- 
caine locally, but it is well to bear in mind that this is a very 
dangerous measure." 

If there is balanitis, the remedies are mere, eor.^ mere, sol., 
thuja, and local applications, as calejielula ; in valvitis, arseni- 
eum, thuja, mereuriiis. 

Cases due to masturbation or nervous diseases belong under 
consideration of the treatment of the latter disorders. 

For incontinence referable to uricemia (lithemia), see treat- 
ment under heading Urigemia. Diet and the benzoates are use- 
ful when uricemia is a cause. 

When the cases are dependent upon irritability of the blad- 
der, belladonna, in lo to 20 drop doses of the tincture, or atro- 
pinesulpJiaie, one grain in an ounce of water, given in doses of 
one drop for each year of the child, at four and at seven even- 
ings, so as to have the pupils dilated during hours of sleep. 
The dose at bedtime need not be given if the child's pupils are 
well dilated, and in the case of small, feeble children, great care 
must be taken in giving atropin. Moreover, atropin is not a 
specific. 

In cases apparently due to lack of tone in the sphincter, rhiis 
aromatiea is certainly of service ; dose from 4 to 10 drops of 



ENURESIS— TREATMEXT. 499 

the fluid extract four times daily, gradually increased to from 
8 to 20 or 30 drops, according to age of child. If given in too 
large doses at first, it may disturb the digestion. Children two 
to six years old may take 10 drops night and morning, other 
children 15 drops. Its favorable effects may not persist. In 
one of my cases the child did not wet the bed in those nights 
in which he took 30 drops before going to bed ; in nights when 
he did not take the remedy he infallibly wet the bed. 

Ferrum muriaticuin has been recommended ; 2 drops of 
liqiLor ferri inuriatici in a wine-glass full of water, tablespoonful 
every three hours during the day.* Gelsemiiim, eqiiisetiim, 
cupatorium, Pulsatilla are credited with cures. 

In cases of atony of the sphincter, electricity is advised. 
Ultzmann held that the best treatment is indirect stimulation 
of the sphincter through the rectum. He used the ordinary 
Dubois-Reymond sledge-battery, armed with one element. One 
pole of the induced current is a metallic pin the size of a lead 
pencil, and seven centimetres long, with a wooden handle ; the 
pencil, being well oiled, is passed into the rectum. The other 
pole is an ordinary sponge-holder, which, in boys, is placed on 
the raphe of the perineum, but in girls in the crease of the but- 
tock. The current at first must be very weak and gradually 
increased. Sittings to be held daily, or every other day, and to 
last five to ten minutes. Treatment lasts four or five weeks. 

In spinal cases nux vomica or strycJinin^ third to sixth deci- 
mal according to age. In hysterical children, the valerianates, 
bromides, etc. 

Tincture of equisetimi may be given as follows : one drachm 
to fourfluidounces of water, two teaspoonfuls every three hours. 
If there is constipation, give enema of soap and water before 
going to bed, and after the bowels have moved place supposi- 
tory of one grain of belladonna in the rectum. If for any cause 
diurnal incontinence take place, it should be inserted night and 
morning both. Abstinence from meat and liquids at night 
should be enjoined, and five-grain doses of benzoic acid given 
three times daily when the urine is hyper-acid. 

Cold sponging night and morning is often beneficial as an 
adjuvant. 

Miscellaneous Notes on Treatment. — In the Hahnemannian 
for July, 1893, Dr. Goodno describes two cases as follows: 

"Some months since Dr. Myers called my attention to the 
value of equisetum as a remedy for nocturnal enuresis, stating 
that he had treated several cases successfully. Having had 
two cases on hand for about four and six years respectively, 



*See Mitchell's " Diseases of the Kidneys, "* page 366. 



500 THE DISEASES OF CHILDREN. 

and treatment not having been attended by any substantial 
benefit, I decided to make use of it. 

" Case I. was a boy, aged thirteen years, who came under my 
care when he was seven years old, and whom I have treated 
intermittingly ever since. He has regularly, each night, satur- 
ated his bed, with rare exception, since he was a baby. Had 
given many remedies, performed circumcision, and applied a 
variety of ' methods ' with almost no result. There was no 
incontinence during the day. Equis. o gtt. x three times daily 
arrested his disease at once. During the first three weeks of 
trial a mishap occurred only twice. During the next three 
weeks it occurred five times, but four were after his medicine 
had given out. The past month he has had 15 to 20 drops of 
o three times daily, and has had only two errors. While this 
boy is not cured, it must be confessed he is making great strides 
toward a favorable result. 

" The second case is that of a little girl seven years of age, 
who has, like the boy, had incontinence since babyhood, but, 
unlike him, her trouble has been diurnal as well as nocturnal. 
Most days she wet herself two or three times daily. She is a 
very nervous child ; indeed, has positive hysteria, indicated by 
the globus Jiystericiis, and a wide range of hysterical symptoms. 
At times there has been a little improvement from remedies, 
but never any marked change until I gave her valerianate of 
ammonia, in grain doses, four times daily. This remedy not 
only helped her hysterical condition, but she would go a week 
without any mishap during the day, and miss, perhaps, every 
other night. After a time it failed to accomplish anything, 
and I gave it up after varying the dose considerably. Equise- 
tum o gtt. v., three times daily, arrested the whole trouble 
immediately ; not a single mishap occurred, day or night, for a 
week. Since that time the child has occasionally wet herself, 
both at night and during the day, but the errors have been 
rare." 

Dr. Van Baum writes me that he has not had flattering suc- 
cess from use of equisetum. Personally I have had no experi- 
ence with it worth mentioning. 

Liebault has cured nocturnal incontinence in hysterical, or 
at least neurotic, children, by hypnotic suggestion. 

F. C. Simpson has seen a number a cases which, treated with 
every possible care and with every drug known, still continue 
to wet the clothing, though not the bed at night. In his opin- 
ion, these cases are referable to masturbation, and he has cured 
a number by blistering the penis. 

Overpeck, in the Pulte Quarterly, reports four cases as follows : 

*' I. The young man is well nourished, has a fair skin, blue 



ENURESIS— TREATMENT. 501 

eyes, and brown hair. Is restless in his sleep, but hard to waken. 
Feet are always damp from perspiration. Is very fond of 
sweet things. Has no trouble with urine except at night. 
Gave sulphur. 

** 2. The sister is similarly organized, and the description 
above will apply to her with these few exceptions : Hands 
are always cold. She sleeps quietly, and has this symptom 
which is so characteristic of the remedy she received : frequent 
and very urgent calls to urinate during the day, and these more 
frequent when at rest than when exercising. Who would not 
say rhus tox.f 

"They began by taking the medicine in the sixth dilution six 
times per day, the interval afterward being gradually length- 
ened, and the attenuation raised to the two hundredth. After 
taking these for five or six months, a letter informs me that the 
son is entirely well, and has been away from home on a vaca- 
tion trip, which is the first in his lifetime. The sister is pro- 
nounced about cured. 

'* 3. A boy of five years, rather thin, abdomen large. Cervi- 
cal glands are slightly enlarged at times. Urinates frequently, 
and that passed involuntarily at night is very offensive and 
profuse. He is particularly fond of sweets, and at times has 
indications of the presence of stomach worms. He has been 
doctored by a ' regular,' and finally circumcised, all to no pur- 
pose. In this case I gave calc. carb., with occasionally a few 
powders of santonin^ then followed these with sulphur. This 
may not have been scientific prescribing, but it did the work in 
a few weeks. 

''4. Boy of three years, subject to epileptic attacks. Has a 
large head. Was slow in teething and walking, and had eczema 
on face and scalp. Calc. carb. has cured the urinary weakness, 
and the general condition of the patient is much improved." 

Dr. Sereno used electricity in the case of an unmarried 
woman who had had enuresis from childhood. The interrupted 
current was employed with a large wire. One pole in the form 
of a plate was applied over the abdomen, and the other brought 
into contract with the sphincter of the bladder by means of a 
vesical sound. The current was of supportable intensity and 
was applied for five minutes three times a week. After eight 
sittings the patient wetted her bed only one night out of every 
two and retained her urine very well during the day. A com- 
plete cure is expected. 

Aldrich, of Minneapolis, cites a case of a girl of six in which 
albumin was found, which disappeared when rectal and biman- 
ual massage had restored the pelvic organs to their normal tone. 
He thinks well of massage of the bladder per rectum, together 



502 THE DISEASES OF CHILDREN. 

with a daily salt-water bath, accompanied by brief rubbing 
in the region of the spine, with attention to hygiene, diet, and 
psychical surroundings. 

In the treatment of enuresis, Taylor suggests as an adjuvant 
that the bed be tilted, so that the child may lie with heels high 
and head low. An admirable rule is that the bowel be thor- 
oughly cleansed by an enema a short time before going to bed. 
The following remedies have been useful in certain cases : 

Hyoscin hydrobromate, in doses systematically increased until 
certain disagreeable symptoms, as over-dryness of the throat 
and nose, and dimming of vision, are observed. In many cases, 
desirable results are obtained before these symptoms appear. 
CantJiarides in small doses slowly and cautiously increased, may 
be given at the same time. PJiosphate of sodium, if there are 
digestive disturbances. Circumcision is an extreme measure, 
although at times a proper one. Taylor thinks it quite suffi- 
cient to strip the parts thoroughly, making sure that readhesions 
do not occur. 

Milk diet is advised during treatment. 

H. A. Husband in the Canada Lancet reports the following: 
''The case was that of a boy, aged 19 years, the eldest of four 
sons, all of whom had been troubled with the same complaint 
since birth. The patient had at various times been treated 
with tincture of belladonna, but with no apparent benefit. It 
was found that the boy suffered from chronic constipation, 
which was relieved by a pill of extract of rhubarb and nux 
vomica, given night and morning. 

" The lower bowel was washed out every night with an 
enema of warm soap and water, and then a suppository con- 
taining one grain of belladonna placed in the rectum. The 
object of the enema was to clear out any hardened feces or 
thread-worms, which, by their presence, might by their irritation 
produce the incontinence. This treatment was rigidly contin- 
ued for three months with some slight benefit, a week or two 
passing without a return of the complaint. The amount of 
belladonna was now increased to a grain and a half. And then 
a new symptom made its appearance. The nocturnal incon- 
tinence ceased, but the patient during the day became troubled 
with a constant desire to pass water, the annoyance being so 
great that he had to micturate every five minutes. The sup- 
pository was then ordered to be used night and morning, with 
the entire discontinuance of the nocturnal and diurnal trouble. 
During the last three months the pupils became permanently 
dilated, but there was no irritation of the skin, and only occa- 
sionally slight dryness of the throat. In six months a complaint 
which had lasted nineteen years was completely cured, and the 



ENURESIS— TREATMENT. 503 

patient was enabled to proceed to the continent on his busi- 
ness, taking with him a mixture containing nitro-muriatic acid, 
strychnin, and gentian. The conclusions drawn from the above 
case are these, that of all preparations of belladonna the extract 
is the best ; that the success in treatment, to a great extent, 
depends on the clearing of the rectum of its contents, and the 
application of the belladonna as near the bladder as possible ; 
and that partial success at first is no reason to discontinue the 
treatment in despair." 

Dr. Day "^ in the British Medical Journal speaks as follows 
in regard to enuresis : 

" Enuresis is sometimes seen in connection with chronic 
albuminuria, and is occasionally so persistent as to require 
special treatment. It seems impossible to lay down a plan of 
treatment for general adoption ; the peculiarities of constitution 
and habits of life must be taken into consideration, and 
hap-hazard treatment guarded against. Some cases are cured 
or relieved by the combined influence of electricity, iron, and 
belladonna. The successful issue is in a great measure attrib- 
utable to the constant care which the mother takes in feeding 
the child and rigorously attending to the physician's instruc- 
tions. Those cases that date from birth or have lasted upwards 
of a year are invariably intractable and often incurable, espe- 
cially if the child be of nervous parentage, or was delicate when 
born, or passes large quantities of urine. With respect to the 
utility of faradism there can be no question ; it requires to be 
used regularly, and to be continued for a considerable time, 
but it sometimes fails altogether. When the nervous system is 
weak, and there is general debility, the sphincter loses its 
power, and urine escapes by night and day without the child's 
knowledge. It is in such cases as these that iron and nux 
vomica are of service. 

" If there be excess of muscular action, and the child have 
frequent inclination without power to control, belladonna is an 
admirable remedy. It occupies a prominent place as a thera- 
peutic agent, and sometimes when combined with iron, even in 
small doses, it seems to do good ; but it should not be given 
up in obstinate cases, till either soreness of the throat is pro- 
duced or dilatation of the pupils takes place. In Dr. Day's 
hands it has often failed when administered in any form or 
dose. It certainly tends to lessen irritability of the bladder, 
and should always have a fair trial. 

" Cold sponging in the morning is very serviceable in cases of 
enuresis that appear to have their origin in general debility. It 



* Tlierapeutic Gazette. 



504 THE DISEASES OF CHILDREN. 

braces up the nervous system and is a powerful tonic. The slight 
sensation of chilliness soon passes away without leaving any de- 
pression if vigorous friction with a towel be employed for a 
few minutes. In a case under Dr. Day's care about three years 
ago, the cure was attributed to this simple measure when one 
remedy after another had failed. The vital functions are 
brought into a healthier state, the skin acts better, and the 
appetite and digestion improve. However delicate a child may 
be, free sponging in tepid water, folllowed by a good rubbing, 
is of great value." 

Kupke expresses the opinion in the Allgem. Med. Central 
Zeitimg, that Guyon's method of electrization is most rational. 
This consists in introducing into the urethra, as far as the 
membranous portion, a metallic sound to which an electrode is 
attached, the other electrode being placed over the pubes or 
the perineum. The electric current should be quite weak at 
first. 

Dr. Sanger has found good effects from the mechanical 
method of introducing a metallic catheter into the bladder of 
female children, making firm pressure backward and to the 
sides several times while the thumb covers the aperture of the 
instrument. Ten to twelve sittings are said to be usually suffi- 
cient. Such a mode of treatment, it seems to us, should not be 
entered upon until other milder and safer ones have been tried. 
In all cases we should try the effect of giving but little fluid 
toward evening, taking up the child several times in the first 
part of the night, seeing to it that the bed is a firm and rather 
hard one, and encouraging the child as much as possible to 
avoid sleeping on the back. If these fail, it might be advisable 
in picked cases to carry out the suggestions of a recent corre- 
spondent in The Lancet. His remedy is the birch-rod applied 
before the child is put to bed, not as a punishment, but in a 
true scientific spirit. Six is the regulation number of strokes, 
and they are to be put on where they will do the most good. 
After the third seance the cure is complete. The rationale of 
the method is that it awakens in the boy (girls should be spared 
the indignity) a desire to avoid wetting the bed ; it draws the 
blood to the surface for a few hours, and thus relieves the pel- 
vic organs ; it stimulates the lumbar center, controlling mictu- 
rition through the nerves distributed to the upper gluteal 
region ; and it prevents the patient lying on his back. 

Moral: Spare the rod and spoil the bed, says the Medical 
Record. 

Krauss treats enuresis as follows : In cases due to irritation, 
as tight prepuce, narrow meatus, etc., etc., the cause is removed 
and rJms aroniatica given in five-drop doses, increased to twen- 



EN URESIS— TREA TMENT. 505 

ty-five drops, four times daily. In cases due to central nervous 
disorders, in precocious children, for example, with pernicious 
mental development, etc., he gives rhus aromatica, together 
with the remedy for the nervous element — nervous tonics or 
sedatives, as mix vomica or the bromides. If, in addition, 
there is anemia, he advises the iodide of iron. 

In enuresis of children. Dr. R. B. James has found atropijt 
often effective, so long as its administration was continued in 
full doses. But after leaving off the drug the patients were no 
better than before. His plan was as follows {Archives of Pe- 
diatrics, September, 1890): A solution of atropin sulphate 
was made, of which one teaspoonful represented one-hundredth 
of a grain of the drug. Of this solution, for the first night, 
each child had one teaspoonful at 6 and another at 9 P. M., and 
this to be increased by one teaspoonful every night till a con- 
trolling dose was reached for each case. None of them were 
benefited by less than four-hundredths of a grain at night — that 
is, two-hundredths of a grain at 6 and two-hundredthsof a grain 
at 9 P. M. — while others required as much as eight-hundredths 
of a grain (divided as above) ; one case was given as much as 
one-tenth of a grain at night without showing symptoms of 
poisoning. Nothing short of the quantity that produced full 
physiological effects was of any avail. After the controlling 
dose was ascertained for each case, it was repeated every night 
for about one month, when the drug was Avithheld altogether. 
It was found that many of the cases were relieved, while others 
were not benefited. Of the cases completely relieved, the en- 
uresis returned in all, with one exception, in periods ranging 
from one to six weeks. The case that was cured was a healthy 
boy but slightly affected. These cases were kept under close 
observation for eight months, during which time many of them 
would go without the drug, or on reduced doses, from one to 
four weeks without wetting themselves. But sooner or later 
the relapse would occur and at the end of the eight months, 
they were but little better than when treatment was started. 

A writer in the Medical Record sums up the treatment of 
enuresis by the older school as follows : 

"Attention should be paid to the skin by use of massage, 
sea-bathing, alcohol sponge-baths, frictions with coarse towel, 
etc. Girls from six to twelve years of age or over are most in- 
tractable to treatment, and often there is no use expecting to 
get much relief until lessons and books are absolutely prohib- 
ited, and outdoor. exercises and air take their place. Among 
drugs the principal indication is, first, general tonics, as for in- 
stance, syr.ferriiodidi, syr. hy pop ho s., with nux vomica; cod-liver 
oil, tonic doses of quinin, and arsenic for the bodily condition. 



506 THE DISEASES OF CHILDREN, 

The best drug for the local effect on the bladder-muscles is 
belladonna, but it must be given until dilatation of the pupil to 
a considerable extent is obtained ; the effect of this drug must 
be caref ull)^ watched and the patient given a good deal of atten- 
tion. StrycJinin is a drug of value in these cases, for its gen- 
eral effect as well as for its power over the sphincter vesica. A 
suppository containing one-quarter grain nux vomica intro- 
duced three or four times daily into the rectum has had a very 
good result. Ergot, internally, combined with belladonna or 
strychnin, answers the indications. RJiiis tox, in repeated 
doses of a quarter of a grain of the powdered leaves, is said to 
be very efficacious. The electrical current has been recom- 
mended very highly by German authors for this trouble. It is, 
of course, a powerful local stimulant. One electrode is applied 
to the perineum, the other to the hypogastrium or lumbar 
region. I hesitate about using instruments in the bladder and 
urethra unless there is positive evidence of bladder or urethral 
disease or of foreign body. 

" Yet the skillful and careful introduction in a boy of a steel 
sound large enough to dilate the deep urethra and distend the 
neck of the bladder will often assist greatly in the cure of incon- 
tinence. Ordinarily, and in the ordinary way, the introduction 
of a sound or the use of deep injections is brutal, and likely to 
do a great deal of harm, if it fortunately does not set up a 
cystitis or urethritis which may be very difficult to cure. The 
introduction of a sound when necessary may have to be done 
under ether or chloroform. 

'' The third class of cases, where the children have all the 
muscles active and healthy except those of the bladder, are 
most puzzling. Any probable tendency to, or a constitutional 
disease, is either to be excluded or treated. Very often these 
patients are troubled with no other ailments but this one. It 
may have begun as a nocturnal enuresis and continued as day- 
time incontinence. The sphincters of the rectum are often 
irritable and untrustworthy, complicating the bladder trouble. 

" The remedies mentioned above are also available in this 
class. It may be that, following a long-continued enuresis from 
local or other long-since removed cause, the bladder has become 
contracted or contractured. If so, treatment of such case will 
be long and tedious, and cure will depend on appreciation of 
the physicial condition, the internal remedies above-mentioned, 
and the patience of the surgeon and the patient. I have never 
seen good results obtained in these or similar contracted blad- 
ders by forcible or gradual distention by means of hypostatic 
pressure. 

'' The muscles of the bladder, acting very like muscles 



EN URESIS— TREA TMEN T. 507 

elsewhere in the body, become strengthened and developed 
by exercise. Forcible distention is a dangerous and decidedly 
unsafe method. 

'* In those patients where all other methods have produced 
little result, and where the bladder is not contracted, continued 
washing of the bladder twice daily with a simple salt solution 
will sometimes restore to a certain degree, if not completely, 
the tonicity of the vesical muscles, and bring about a cure. 
This measure is not always practical, and is attended with con- 
siderable risk, which may be reduced to a minimum, however, 
by a skillful surgeon, with clean catheters and hands and a 
tractable patient. 

" Occasionally these cases get well spontaneously, especially as 
they reach the period of puberty, at which time the genito- 
urinary system undergoes rapid changes in its development." 



PART" IX. 

DISEASES OF THE RESPIRATORY ORGANS. 



CHAPTER I. 
GENERAL CONSIDERATIONS. 

There are certain peculiarities of the respiratory apparatus 
in infancy that must be understood in order to properly esti- 
mate the signs of disease in this most important part of the 
economy. The physiological differences in the respiratory 
function between the child and the adult are numerous, and, in 
some respects, they are very marked. 

For example, the rapidity of respiration is much greater in 
infancy, and somewhat more so all through childhood, than it is 
during adolescence or maturity. 

At birth the respirations average from thirty-five to forty per 
minute — a rapidity which in the adult would cause grave ap- 
prehensions. There is not the same regular rhythmical action 
in early life, even in health, that is maintained later on. The 
respiratory muscles, like those of other parts of the infant body, 
work spasmodically, and under every slight disturbance of the 
sensory nerve, the respirations become jerky and irregular. 
While the infant cannot yet see, hear, smell, nor taste to any 
great extent, it can feel, and that most acutely. 

It is through the action of the sensory nerves that the first 
breath is drawn, and for a long time thereafter the respirations 
are easily disturbed by reflex irritation. 

Pauses in respiration are a peculiar, but natural feature in 
childhood, and they are especially marked when the child is 
crying. Goodheart points out what we regard as the true 
explanation of this peculiarity. He says it is not due to mus- 
cular weakness, as some aver, *' but to the as yet imperfect edu- 
cation which is seen in all the muscles, whether of speech or 
of voluntary movement. Hence, also, the Cheyne-Stokes type 
of respiration, which is a paroxysmal one. Children work par- 
oxysmally, whatever the movement in hand. The nervous dis- 
charge takes place, and then comes a pause — another discharge 
(508) 



GENERAL CONSIDERATIONS. 509 

and another pause — and so on ; and it is only as the nerve cen- 
ters reach a higher state of training that the discharges are so 
regulated as to become more continuous." The " Cheyne- 
Stokes " type of breathing, to which reference is made above, 
consists of a series of short, but gradually lengthening inspira- 
tions, culminating in a deep-drawn breath, from w^hich in a 
descending scale, the respiratory movements flutter down to an 
elongated pause. This type of respiration, though much mod- 
ified and its sharper characteristics destroyed, is very often 
seen in infants. This should always be borne in mind in mak- 
ing physical examinations in children, for this disturbance of 
rhythm may mean little or much, as other symptoms are present 
or absent, to render it normal or abnormal. The breathing is 
diaphragmatic in children, and it is sometimes difificult to detect 
the movement of the upper part of the thorax if the child is 
breathing naturally. In examining a child, therefore, it is nec- 
essary to have the chest thoroughly bare, so that every move- 
ment of the respiratory muscles may be closely observed. For- 
cible movement of the thoracic walls indicates labored breathing, 
and is always present in broncho-pneumonia. Great recession 
of the lower parts of the chest suggests some impediment to 
the entrance of air into the lungs. It should always be borne 
in mind, when examining an infant suspected of pulmonary 
disease, either acute or chronic, that the lungs may never have 
been fully expanded since birth ; or that a collapse of some 
portion of the lung may have occurred as the result of obstruc- 
tion to the entrance of air from catarrhal inflammation. The 
possibility of a considerable portion of the respiratory appara- 
tus remaining useless from birth, or becoming so afterwards, 
without any serious disease of these organs, is a most impor- 
tant element in the pathology of infancy and early childhood. 

Indeed, the dyspnea, the hurried breathing, and many other 
symptoms which are referable to obstructed respiration maybe, 
in a given case, not due at all to the beginning or progress of 
an inflammatory process, but to the non-expansion or imperfect 
expansion of the lungs. 

Sometimes mere feebleness of the respiratory power is re- 
sponsible for this failure of certain portions of the lung to par- 
ticipate in the respiratory act. The pulmonary cells are more 
and more emptied of air at each expiration, and the weakness 
of the chest-walls is such as to render their subsequent inflation 
impossible. Collapse of these lobules is the natural result. 
Where but a small portion of the lung is thus incapacitated, it 
is often difificult to diagnose the trouble ; but the breathing is 
more rapid than it should be, and there is no fever to indicate 
that an inflammatory process is going on. 



510 THE DISEASES OF CHILDREN. 

Auscultation sheds but little light upon the case. Percussion, 
if carefully conducted, will afford more satisfactory results, for 
limited areas of dullness will be apparent. The chest of a child 
is more sonorous than that of an adult ; that is to say, a more 
resonant sound is elicited when percussion is resorted to. In 
percussing the chest of a child, one finger should be laid firmly 
on the outer wall of the chest, while one or two fingers, held 
vertically, tap it slowly but lightly. In this way a good reso- 
nant sound should be elicited anywhere, although in children, 
as in adults, the apices and the scapular region vary much in 
resonance in conditions of perfect health. The stethoscope 
should always be used in auscultation of infants and children. 
The ear, however well trained, cannot be depended upon to 
detect those very limited areas of congestion or consolidation 
which are so partial in their distribution as to require for their 
detection that the chest be gone over inch by inch, and a care- 
ful comparison instituted between the two sides. It is well to 
remember, in making these examinations, that the pitch of both 
the inspiratory and expiratory sounds is higher in children than 
in adults. The intensity or sharpness of the respiratory mur- 
mur is what has given rise to the term '* puerile respiration." 
This should not be confounded with tubular or bronchial breath- 
ing. In this case, the inspiratory sounds are shortened, and 
there is a distinct interval of silence between it and the expira- 
tory sound, which is higher pitched, louder, and more prolonged. 
This is just the reverse of normal breathing. When there is 
pleuritic effusion in one side of the chest, it does not especially 
alter the respiratory murmur over this side, except at the apex, 
where it often gives rise to tubular breathing; but it is apt to 
intensify the puerile character of the respiration on the well 
side in a very misleading fashion. Unless care be exercised, the 
mistake is easily made of regarding this enhanced intensity of 
sound to disease of the well side, which can only be avoided by 
regarding the fixed or immobile condition of the parts actually 
involved by the pleurisy, and by a careful comparison of the 
percussion sounds of the two sides. 

Another peculiar feature of disease involving the pulmonary 
tissues of infants, is the insidious manner with which it creeps 
along, or may creep along, sometimes rapidly, but at other 
times slowly, invading one portion of membrane after another, 
until a slight and localized inflammation, scarcely worthy of 
special notice, suddenly breaks out into a widely extending and 
serious affection. Thus, a trifling nasal catarrh may extend into 
the throat or into the trachea, and from thence into the bron- 
chi ; and a case of '' snuffles " eventuates in a capillary bron- 
chitis or a catarrhal pneumonia. The greatest care should be 



COUGH. 511 

taken, therefore, to watch the incipiency of all pulmonary af- 
fections occurring in early life, and so far as possible, prevent 
their extension by prompt and ef^cient treatment. 

COUGH. 

Cough is a symptom which, to a greater or less extent, accom- 
panies all affections of the respiratory apparatus, but it is also 
a symptom of variable significance, and may be present to an 
annoying degree, independently of any pulmonary lesion. The 
stomach cough of children is traditional, and is caused by irri- 
tation of some fibers of the vagus. Other varieties of cough of a 
purely reflex character are by no means uncommon. Foreign 
bodies in the ear will excite a reflex cough, which disappears 
as soon as the cause is removed. Dry wax in the ear will pro- 
duce the same phenomenon. Umbilical protrusion has been 
reported as the exciting cause of violent cough in a young 
infant, which was promptly relieved by replacement and com- 
pression. There are fairly well authenticated cases where the 
expulsion of tapeworm, (lumbrici), lumbricoids and other par- 
asites from the alimentary canal, has caused the immediate 
arrest of a persistent and vexatious cough. One of the most 
frequent and troublesome of these reflex coughs met with in 
children is the so-called *' night cough," which comes on with 
great regularity just before midnight. It is short, dry and evi- 
dently of an irritative character. It is believed to be of nasal 
origin, and is due to the presence of mucus in the nasal or 
naso-pharyngeal chambers. During the day, w^hen the child is 
up and about, this mucus, then in a fluid state, escapes anteri- 
orly ; but in the recumbent posture it accumulates, and becom- 
ing dry, causes a turgescence of the posterior nasal erectile 
tissues, with the reflex phenomenon of cough. Follicular phar- 
yngitis, acute and chronic, hypertrophy of the tonsils, so com- 
mon in children, and an elongated uvula, will all give rise to 
cough, which is often paroxysmal, sometimes suffocative and 
always obstinate. A reflex cough, strikingly like that ob- 
served in pertussis, is occasionally caused by enlarged bronchial 
glands. This cough is noisy and paroxysmal, but is not at- 
tended by a whoop. This fact, and its non-appearance in 
epidemic form, affecting only a single individual, serves to 
differentiate it. The absence of any definite and distinctive 
stages, and the evidence of associated lung disease, also serve to 
remove any doubts that may exist as to its non-specific charac- 
ter. Enlarged bronchial glands have also a history of wasting 
long before the occurrence of the cough. The diagnosis of 
this affection is aided greatly by following the method of exam- 



512 THE DISEASES OF CHILDREN. 

ination laid down by Eustace Smith. He says: "If the child 
be made to bend back the head, so that his face is almost hori- 
zontal, and the eyes look straight upwards at the ceiling above 
him, a venous hum, varying in intensity according to the size 
and position of the diseased glands, is heard with the stetho- 
scope, placed upon the upper bone of the sternum. As the 
chin is now slowly depressed, the hum becomes less loudly 
audible, and ceases shortly before the head reaches its ordinary 
position." 

However we may regard the philosophy of the production of 
the cough in a given case, or however puzzled the pathological 
condition underlying it, our practical ends are best subserved 
by finding a remedy that will relieve it. In some cases, where 
the pathological lesion is incurable, this will be hard to accom- 
plish ; but oftentimes a distressing cough, that in the nature of 
the case is incurable, may be ameliorated by finding a drug 
which gives rise in its pathogenesy to a cough of similar 
character. 

To this end the following list of remedies and their indica- 
tions will prove helpful. 

REMEDIES. 

Tight Cough. — Hepar sulph., phos., puis. 

Dry, — Aeon., bell., con. mac, gels., hyos., nux vom., phos., 
rumex., sepia. 

Loose. — Ant. tart., hepar sulph., phos., calc. carb. 

Rattling. — Arg. nit., ant. carb., ipecac, secale, sepia. 

Deep. — Arg. nit., hyos., phos., sticta. 

Racking. — China, eupat. perf., phos., secale, sepia, arn. 

Hacking. — Puis., sepia, sulph., phos. 

Titillating. — Am. carb., cham., auphras., hyos., ign., ipec, 
lauxoc, sepia. 

Paroxysmal. — Bell., dros., cup. met., gels., hyos., ipecac, phos., 
cor. rub. 

Moist. — Ant. tart., calc. carb., ipec, kali, bi., sulphur. 

Nervous. — Aeon., ambr., coff. crud., gels., hyos., ign., kali, 
brom., platina. 

Spasmodic. — Badiaga, bell., cup. met., dros., gels., hyos., ipe- 
cac, mangan. 

Barking. — Bell., bry., caust., aeon. 

Hoarse. — Hepar sulph., sticta., carbo. veg., ign. 

Hollow. — Bry., aeon., bell., nit. acid, spongia. 

WJieezi7ig. — Spongia, aeon., bell., hyos. 

Aggravation — Morning. — Apis, baryta carb., bry., calc. carb., 
calc. phos., caust., china, coff. crud., crocus, fer. met., ign., ipec. 



Sl'MP TOM A TOL OGT. 513 

lach., nat. mur., nux vom., rhus tox., sang., sepia, silic, stram., 
thuja, am. carb. 

At night. — Aeon., alumina, ambra, ant. tart., apis, arg. nit., 
ars. alb,, bell., bry., calc. carb., calc. phos., carbo veg., caust., 
cham.., china, conium, dros., fer., hyos., lycop., mere, sol., 
mere, corn, nit. ac, phos. ac, puis., silic, spong., sticta., thuja, 
verat. alb. 

On eating. — Ant. crud., bry., calc. carb., calc. phos., china, 
conium, fer., hepar sulph., kah bi., lach., mere, corr., nux vom., 
phos. ac, puis., sepia. 

On drinking. — Ant. crud., bell., calc. carb., china, fer., hepar 
sulph., ign., lach., opium, phos. ac, rhus tox., silic 

From excitement. — Nux vom. 

From exercise. — Apis, calc carb., china, kali bi., mere sol., 
nat. mur., nit. ac, spong., stannum. 

On motion, — Ant. crud., bell., bry., calc. carb., calc phos., 
china, fer.,. gels., mere corr., nux vom., rhus tox., sang., 
stannum. 

From cold. — Ant. crud., bell., calc. carb., calc phos., hepar, 
lach., mere sol., phos. ac, rhus., silic, sulph. 

From, warmth. — Aeon., ant. crud., apis, bell., bry., fer., lach., 
mere, sol., nat. mur., opium, phos., puis., sulph. 

On lying down. — Aeon., conium, dros., hyos., ign., kali, carb., 
mere, sol., nat. mur., nit. ac, phos., puis., silic, sticta. 

SYMPTOMATOLOGY— SPECIAL INDICATIONS. 

Aconite. — Especially in first stage ; cough hoarse, dry and 
short, or loud, hard and ringing ; fever, dry, hot skin ; restless- 
ness ; child grasps throat when coughing ; cough worse at night 
and better while lying quiet. 

Arse7ticum. — Fever, cold, clammy perspiration ; great thirst ; 
suffocative cough at night ; cannot lie down ; pale, waxy skin, 
wuth great prostration. 

Belladonna. — Face red, head congested ; cough is short, dry 
and violent, or spasmodic, hollow or barking ; short, anxious, 
hurried breathing. 

Causticum. — Cough dry, hollow and violent ; worse in morn- 
ings and evenings, but better w^hen warm in bed and from 
swallow of cold water ; short, hurried, panting respiration, with 
involuntary discharge of urine and feces. 

Chamomilla. — Child is peevish, fretful, variable mood ; severe 
dry cough during sleep without awakening ; paroxysms of suf- 
focative cough at night ; especially useful during dentition. 

China. — Hoarse, tickling, spasmodic cough, worse at night, 
after eating, laughing or cold ; prostration, without thirst. 
D.C.— 33 



514 THE DISEASES OF CHILDREN. 

Hepar sitlph. — Cough deep, rough, barking, or hoarse and 
rattHng ; cough excited by cold, uncovering any portion of 
body, eating or drinking anything cold, and crying ; cough 
worse in morning and better from warmth. 

Gelsemium. — Paroxysms of hoarse, spasmodic cough ; child is 
dull, languid and apathetic ; excessively nervous ; loss of appe- 
tite. 

Ipecac. — Vomiting ; long-lasting retching ; cough causes vom- 
iting ; paroxysms of long-lasting, violent cough, until child loses 
its breath and gets blue in face ; convulsions and spasms from 
cough. 

Merc. sol. — Alternate heat and chilliness ; great thirst for 
cold water ; cough short, dry and ringing ; worse at night and 
from drinking cold water. 

Niix vorn. — Fever, thirst, alternate diarrhea and constipa- 
tion ; dry, short, violent cough, worse at night ; cough worse 
after eating, drinking, cold, and lying on the back ; involuntary 
urination while coughing ; especially useful after patent medi- 
cines and cough mixtures. 

Phosphorus. — Emaciation, with weakness and prostration ; 
cough tight, tickling and dry ; loose, hollow and rattling ; worse 
at night, from eating, laughing, motion and cold ; better from 
rest and quiet. 

Pulsatilla. — Inclination to stretch, yawn and throw off the 
clothes ; chilliness, without thirst ; cough dry and tight at night ; 
loose during day ; worse in evening and on lying down ; better 
on sitting up. 

Sulphur. — Child jumps, starts and screams ; head hot and 
body cold ; cough short, dry and violent ; worse evenings and 
when lying down ; hoarseness with hurried respiration. 

Tartar Efnetic. — Child wants to be carried, very restless and 
cries when touched ; cough short, shrill, moist and rattling ; 
cough causes suffocation, compelling patient to sit up ; cough 
worse when lying down ; is followed by gaping, dozing or crying. 

Sambucus. — Rough, wheezing, suffocative cough,* waking 
child about midnight ; cough causes child to sit up, wheeze and 
gasp for breath, turn blue in the face ; cough worse at night, 
and while at rest, but better while moving about ; follows well 
after opium. 



CHAPTER II. 

CORYZA (nasal CATARRH). 

The mucous membrane of the nares is exceedingly suscep- 
tible to catarrhal inflammation, and coryza is one of the most 
frequent of infantile maladies. In its most frequent form it is 
more a source of discomfort than danger ; but it must not be 
regarded as a trifling disorder, for oftentimes a simple coryza 
paves the way for a more extended and serious disorder. It 
seems to be a well-established fact that diphtheria, laryngitis, 
pneumonitis, bronchitis and indeed all of the affections of the 
throat and lungs are most common in those who are the previ- 
ous subjects of catarrh. 

This statement is equally true of tuberculosis. Any impedi- 
ment to the free entrance of air to the lungs ; anything which 
embarrasses the respiratory function to any appreciable degree, 
is apt to lead to congestion, infarctions, and as a secondary 
effect, to glandular changes of more or less serious moment. 
We have already, under the head of General Considerations, 
spoken of the facility with which all inflammations of the 
mucous membrane lining the respiratory tract, spread and 
extend themselves; and a slight and inconsequential catarrh 
may terminate in a fatal laryngitis or a serious affection of pul- 
monary lining, or parenchyma. Some children seem to be 
much more subject to catarrhs than others. There are babies 
that *' snuffle" from the first hour of their extra-uterine exist- 
ence ; while others, apparently no better cared for, seem to be 
almost exempt from colds and their consequences. Undoubt- 
edly constitutional dyscrasia has much to do with this, for as a 
rule, children that are " always taking cold " are of a scrofulous 
or strumous habit. It must be admitted, however, that per- 
fectly healthy children in all other respects, once the vitality is 
lowered by one of the eruptive fevers, or by an attack of indi- 
gestion, take cold very readily, and one cold is very prone to 
be followed by another, and another. During the period of 
dentition this is generally very apparent, for the teething pro- 
cess is exceedingly apt to be complicated by colds taken in 
endless repetition. Slight variations of temperature now in- 
duce catarrhal seizures; or even, independently of any such 
exciting cause, the mere approach of a tooth towards the 

(515) 



516 THE DISEASES OF CHILDREN. 

surface of the gum, often gives rise to its symptoms, which sub- 
side when the source of irritation ceases. As pointed out by 
West, such attacks often alternate with attacks of diarrhea, or 
the two co-exist ; the symptoms of disturbance of the intestinal 
mucous membrane predominating at one time, those of disturb- 
ance of the respiratory membrane at another. 

A large proportion of the ailments of infancy is the direct 
result of the extreme susceptibility of these two great mucous 
surfaces, and just as the flux of to-day may to-morrow take on 
symptoms of acute dysentery, so the catarrh of to-day may to- 
morrow have put on the grave features of acute bronchitis. 

In the first stage of coryza the mucous membrane of the 
nasal passages is unusually dry, but this is quickly succeeded by 
a discharge, more or less copious, of glairy thin mucus, which 
after a time becomes altered in character ; it is thicker, ichorous 
and puriform. In some cases, it becomes dry and forms thick 
crusts about the nostrils, which almost occlude the nares and 
render breathing through the nose an impossibility. Breathing 
by the mouth renders the tongue and throat dry and parched. 
Whenever breathing through the nose is seriously interfered 
with, a child at the breast is unable to suck, and as soon as it 
has seized the nipple it is compelled to let go, to avoid impend- 
ing suffocation. 

In this way the child is not only harassed by obstructed 
respiration, but in neglected or persistent cases, is worn out or 
exhausted by lack of nourishment. Such cases are extreme 
and exceptional, but they do occur, and in weaklings such a 
result should not be forgotton as among the possibilities. The 
cause of coryza is generally " taking cold," but other causes are 
well known to produce the same results, such as the inhalation 
of irritating vapors, steam, hot air and dust. A foreign body 
in the nose, such as a bean or a button, may also, by its pres- 
ence, set up a most offensive and purulent discharge, baffling 
all the usual means of relief, until the foreign body is removed. 

Coryza, as a complication or as a secondary complaint, is fre- 
quently met with in whooping cough, measles, scarlet fever, 
diphtheria and secondary syphilis. 

Syphilitic coryza is often extremely intractable, and will sel- 
dom yield until the constitutional disease has been brought 
under subjection. A sharp coryza, it should be remembered, is 
very often the avant courier of measles, and rarely, although 
occasionally, is of diphtheritic origin, and may be so when there 
is no visible lesion in the pharynx or elsewhere. There is 
usually some slight febrile movement associated with acute 
coryza, and the infant or child is restless and fretful. In nursing 
babes the inability to suckle adds the pangs of hunger to the 



CORTZA {JVASAL CATARRH). 517 

other sources of discomfort, and in their frantic efforts to ap- 
pease their appetites, the catching of the breath through the 
mouth often resembles an attack of laryngismus stridulous, and 
may be mistaken for acute laryngitis. In older children this, 
of course, does not occur, but even they often experience great 
difficulty in eating and drinking. 

Treatment. — Whenever there is ground for suspicion — judg- 
ing from the age of the child, or the character of the discharge 
— that the coryza may be due to mechanical obstruction other 
than inflammation and swelling, an examination of the anterior 
nasal chambers should be made by means of a small rubber ear- 
speculum or nasal dilator, into which a beam of strong light should 
be reflected. Such an examination may be rendered quite 
painless by inserting into the nostril a pledget of absorbent 
cotton, wet in a four-per-cent. solution of cocain. This should 
be left in situ for from five to seven minutes before the exami- 
nation is begun. It will not do to apply the cocain by means 
of an atomizer, because it cannot be sufficiently localized in its 
anesthetic effect, and for the added reason that a toxic amount 
of it is liable to be thrown far enough back to be swallowed. 
If foreign bodies or neoplasms are discovered, they should, of 
course, be removed. 

For simple catarrh, especially in young infants, little treat- 
ment is usually necessary. The nares should be carefully 
cleansed with warm water as often as they become obstructed, 
and a little goose grease, olive oil, or cosmoline should be 
smeared on the outside of the nose and lips, and inserted within 
the nares by means of a small pledget of cotton. All powders 
of an astringent nature, such as tannin, alum, nitrate of silver, 
sulphate of zinc, should be religiously abstained from ; and the 
same should be said of all astringent washes or sprays. They 
are unnecessary, and do positive harm by irritating and congest- 
ing the already inflamed mucous membrane, and only make 
matters worse instead of better. Infants at the breast, and 
who are temporarily incapacitated from nursing, should be fed 
with a spoon until the stenosis is reHeved. Those who are sub- 
ject to frequent attacks of coryza from taking cold, should be 
made to wear constantly a light flannel cap, as suggested by 
Dr. Charles D. Meigs. 

Children who are old enough, can be readily cured of either 
acute or chronic nasal catarrh, if uncomplicated, by the persist- 
ent use of a weak solution of sea-salt. 

It is over twent)^ years since we read in a medical journal the 
experience of a French physician, whose name we have now 
forgotten, who noticed the beneficial effects to his patients suf- 
fering from catarrh, from visiting the seashore and bathing in 



518 rHE DISEASES OF CHILDREN. 

salt water. Taking the hint from numerous cures effected in 
this accidental way, he began using the sea water, which he had 
brought to him for the purpose at his home in the interior, and 
with a success that eclipsed all of his former efforts. Since 
that time, we have ourselves used a solution of sea-salt in our 
own practice, both with adults and with children of suitable 
age, and the treatment has been uniformly successful when 
faithfully carried out. It should always be used warm and the 
solution should be only strong enough to faintly taste of the 
salt. The treatment should be used several times daily, and 
should be continued until a cure is effected. 

It may be used as a spray with an ordinary atomizer, after 
having cleansed the nostrils as far as possible with water as 
warm as can be comfortably borne. It will not do to use a 
douche with this or any other medicinal liquid, for the turbi- 
nated surface is too sensitive, and inflammation is liable to be 
excited, which will extend up the eustachian tube and involve 
the middle ear. 

Hydrastis is a remedy of great value in coryza, and may be 
used in the manner spoken of above. The aqueous fluid ex- 
tract (colorless) should be used for this purpose, one-half or 
two-thirds diluted with warm water. 

The remedies which will be found most useful for internal ad- 
ministration in coryza, and which will often be found sufficient 
without resorting to local applications, are allium cepa, arseni- 
cum alb., mix vomica, naphthaliii ; sambuciis, siilpJiur and tartar 
einetic. 

Special indications for the employment of each of these 
drugs is not deemed necessary. Their relative value and appro- 
priateness in simple coryza will be found usually in about the 
order given above. 



CHAPTER III. 

EPISTAXIS. 

Nosebleed is of very common occurrence in childhood, and 
arises from a multiplicity of causes. Indeed, the conditions 
under which it occurs are so various that it is impossible to 
enumerate them all. Some children suffer again and again, 
even when not otherwise out of sorts ; and without any ten- 
dency to bleeding elsewhere. Sometimes, however, it serves to 
usher in some acute disorder, such as one of the exanthemata, 
pertussis or acute pneumonia. It is said that, with the single 
exception of the horse, man alone among animals is subject to 
this form of hemorrhage. In horses it is exceptional, and only 
occurs under the most violent exercise. 

In childhood it occurs so frequently that there probably are 
few persons who have not at some period experienced it. At 
one time, and for a very considerable period in medical history, 
artificial blood-letting was advocated and supported by the 
statement that spontaneous bleeding from the nose was na- 
ture's safeguard against plethora ; that it not only produced no 
appreciable harm, but, on the contrary, seemed salutary in its 
effects. Rhinoscopic examination of the nares of children, 
shortly after a hemorrhage, shows that in at least seventy-five 
per cent, of the cases, the bleeding takes place from certain 
fixed points or areas, which have been designated the '* hem- 
orrhagic points," or "points of predilection." Apparently these 
are points of least resistance. Blowing or picking the nose, 
vomiting, coughing, sneezing, are all liable to produce a sudden 
engorgement of the nasal mucous membrane, capillary rupture, 
and epistaxis. Nosebleed is rarely observed in the new-born 
or suckling, but becomes more common as the child advances 
toward puberty. Boys are said to be much more subject to 
epistaxis than girls, but this is probably due to their more 
boisterous play, and the more vigorous character of their 
exercise. 

The prognosis in epistaxis is always good. Barthez, Rilliet, 
and Valliers, who have made a critical examination of a great 
number of recorded cases, have failed to find a single one of 
primary epistaxis in children that has proved fatal. In most cases 

(519) 



520 THE DISEASES OF CHILDREN. 

of this kind no treatment is necessary. The hemorrhage ceases 
spontaneously after a time in most cases by coagulation. If from 
any cause the density of the blood is diminished, and coagulation 
takes place slowly, a dangerous hemorrhage, attended by pros- 
tration, faintness, delirium, and cardiac weakness, may result in 
consequence. In such cases active measures, even to plugging 
the nostrils, if other means fail, must be resorted to. Rest in 
the sitting posture is of primary importance, with the head in- 
clined slightly forward, as in writing. This position of the head 
places the floor of the nostrils in a horizontal plane, and pre- 
vents the flow of blood into the pharynx. The mind of the 
patient should be quieted, and all fear and excitement dispelled. 
The nostrils should be compressed, and all attempts to expel 
the clots prohibited. Ice water should be applied to the fore- 
head and nape of the neck by means of compresses. Sometimes 
hot applications will answer better than cold. A piece of ice 
inserted into the bleeding nostril will often prove effectual. 
Galen's method of arresting nasal hemorrhage was to apply a 
large cupping glass to the hypochondria. The expedient is 
time-honored of making firm pressure upon the nostril or the 
septum with the finger of one hand, simultaneously elcv'ating 
the arm of the affected side above the head. 

The most effectual measure, however, in serious cases is to use 
some one of the well-known styptics, one of the best of which 
is a solution of the perchloride of iron. 

The nose should first be cleansed of blood by injection of 
water, after which the perchloride should be sprayed into the 
nostril. The strength of the solution should be 3ii to Sii of 
water. A tampon of cotton or charpie dipped in this same so- 
lution may be used in lieu of the spray. 

A two to five per cent, solution of cocain sprayed into the 
nose or applied by means of small pledgets of cotton introduced 
gently into the nostril, is said to have checked some cases of 
most obstinate hemorrhage. 

Therapeutics. — There are numerous remedies that are of re- 
puted value in epistaxis when administered internally. Of these, 
the leading ones are ^(:^;/zV^, arnica Jiamamelis, belladonna, chinay 
erigeron, and ledum. 

The latter was the favorite of the late Dr. George E. Ship- 
man. Dr. Gilchrist says : '' In cases of epistaxis of almost any 
kind, erigeron has never failed me. I use the strong tincture, 
and administer it by olfaction. One or two smells of it has al- 
ways sufficed." 

In cases where the epistaxis is due to anemia or chlorosis, 
china or ferrum met. should be given, or perhaps still better, 
ferrated cod-liver oil. Dr. S. Hohn says that he has found the 



EPISTAXIS. 521 

fluid extract of hydrastis canadensis " a sovereign remedy in 
these cases ; " he has had occasion to use it in a large number of 
cases of nosebleed in the German Poliklinik (New York), and 
has found it efficacious in preventing a recurrence in a large 
majority of cases. It is administered internally, in ten-drop 
doses in water, every two or three hours. " The hydrastis," he 
says, **is prescribed, be it understood, as a preventive for the 
patient who, at the time of his visit, is not bleeding from the 
nose, but who has a history of repeated bleedings." 

A five-per-cent. solution of the fluid extract of hydrastis in 
water may be used as a spray for the nose ; it may also be used 
with liquid vaselin, albolin, or kindred preparations, as a spray 
or brushed into the nose. The drug seems to " tone " the mucous 
membrane ; and by reason of its containing a bitter principle it 
has, when taken internally, a beneficial effect on the stomach, 
as is attested by the improved appetite following its use ; its 
only drawback is, that it has a tendency to cause constipation, 
but this may be combated by mild salines. 

Dr. Hohn proceeds to give his own method of arresting 
nasal hemorrhage as follows : " It has seemed to the writer that 
the simple rules for the stoppage of capillary hemorrhage are 
appHcable to these cases ; the object is, as in any hemorrhage, 
to secure coagulation at the point of bleeding, and to keep the 
clot in place. 

*' The first rule, therefore, is to place the patient, and more 
especially the bleeding part, at rest ; nervousness or fright should 
be quieted with assurances that there is absolutely no danger ; 
the patient should sit upright in a chair, the head thrown 
slightly backward ; all bands about the neck should be loosened, 
in order that the circulation may be unimpeded ; the patient 
should then open the mouth as widely as possible, and should 
breathe through the mouth only ; breathing through the nose 
should be entirely suspended until bleeding ceases, and should 
be superseded by oral breathing ; blowing the nose, hawking, 
and spitting must be strictly interdicted ; we all know how 
prone patients suffering from nosebleed are to do these things. 
In following the instructions thus far given, the interior of 
the nose is placed at rest, and the first indication is fulfilled ; 
whereas, if the patient snuff up cold water, wipe or blow the 
nose, he displaces clots and favors the continuance of the 
hemorrhage. 

*' The second rule is to tell the patient, his mouth being kept 
wide open, to breathe more deeply and more rapidly than he 
normally does ; the respiration may be increased to thirty per 
minute ; the immediate effect of this increased oxygen supply 
is to increase the force and frequency of the heart's action, and 



522 THE DISEASES OF CHILDREN. 

presumably to increase the amount of blood in the pulmonic 
circulation at the expense of the cerebral ; whether it be due to 
the more thorough equalization of the blood supply to the 
body and head, or to the increased muscular action incident to 
the increased respiratory effort, it has seemed to the writer that 
the nasal mucous membrane is depleted to some extent by this 
procedure. 

" The use of ophun and digitalis in hemoptysis is to a certain 
extent attended by the same result here obtained, viz.^ a more 
powerful contraction of the heart-muscles. 

"As soon as the patient tires of the rapid breathing — which 
he does very soon, perhaps after thirty respirations — he may 
breathe normally for a few moments, when, if the bleeding ha? 
not ceased, he is told to breathe rapidly again ; the mouth is 
to be kept open constantly, and any blood flowing into the 
pharynx to be swallowed. 

"The fact that blood is withdrawn from the brain by this 
procedure is attested, in the opinion of the writer, by the dizzi- 
ness which most patients experience when they resort to it, 
and by the pallor which the face assumes ; the same symptoms 
have been noted by every physician during prolonged auscul- 
tatory examinations of the chest ; some patients are apt to faint 
during such examinations ; it seems to the writer that a tempo- 
rary anemia of the brain is the cause of these phenomena. 

" The final rule is, to tell the patient to enunciate the broad 
vowel 'A' with each expiration ; the soft palate is thus brought 
in contact with the posterior wall of the pharynx during each 
expiration, the posterior nares are separated from the pharynx, 
and the blood is prevented from flowing into the esophagus 
during the expiratory periods. 

" The three principal factors in this simple method of arrest- 
ing nosebleed are, first : to place the nose at rest by suspending 
breathing through it ; second : rapid and profound respiration, 
acting as a respiratory and cardiac stimulant, more equally dis- 
tributing the blood throughout the systemic and pulmonary 
circulation by abstracting it from the head ; and third : the 
occlusion of the posterior nares during the entire expiratory 
period by the intonation of the broad vowel 'A' during expira- 
tion. 

" This method is so easily applicable that after every opera- 
tion in the nose attended by bleeding the writer makes 
use of it ; it is so much cleaner and simpler, after the snaring 
of a vascular polyp or the removal of an exostosis, to make use 
of this procedure than to apply astringents that interfere with 
the field of operation, that it is invariably tried by the writer 
before any other means are applied. Of course it may, in some 



EPISTAXIS. 523 

cases of severe bleeding from a larger vessel, fail ; in these I 
would then try first the insuf^ation of tannin ; and if this fail 
the tamponing of the nostril with long, narrow strips of iodo- 
form gauze, dipped in the glycerite of tannin, with the ends 
hanging out of the nostril. It is needless to dwell on the ad- 
vantages of a method of arresting nasal hemorrhage in which 
no drugs or instruments of any kind are necessary." 



CHAPTER IV. 

TONSILITIS (inflammation OF THE TONSILS). 

This affection is sometimes called quinsy or amygdalitis. 
The tonsils are two almond-shaped glandular bodies situated 
in the mucous membrane at the sides of the base of the tongue, 
just between the two pillars of the fauces. When the mouth 
is opened widely they are thrown forward, and made more 
prominent by the tension of the posterior faucial pillars. They 
are of variable size, being sometimes nearly absent, and again 
are so large as to force the pillars of the fauces out of their 
usual position and make a mass of considerable size in front of 
the pharynx. In bilateral quinsy, they are sometimes so swol- 
len as nearly to touch the uvula. 

According to Lennox Browne, the tonsils, when normal, should 
not protrude beyond the plane of the anterior pillars. This 
variability in size may be considerable without occasioning any 
morbid symptoms, or producing any discomfort to the indi- 
vidual. The tonsils belong to the class of lymphatic glands. 
They are composed largely of connective tissue, in which are 
imbedded numerous follicles, compound in character, whose 
ducts open into one another, and terminate in ten or a dozen 
orifices of variable form. These orifices are plainly visible on 
the surface of the tonsil, and mark the entrances to the crypts 
or lacunae. The arterial supply of the tonsil is abundant, and 
is in proportion to the size of the gland. It comes from the 
inferior pharyngeal and the two palatine arteries, and these 
branches are often so large as, when cut, to give rise to serious 
and even alarming hemorrhage. 

The function of the tonsils has been a matter of much dis- 
pute, and is even now involved in uncertainty. The latest 
researches, however, indicate that their function is two-fold. 

In the first place, the crypts or lacunae, are reservoirs of a 
clear, viscid fluid, resembling in character that which is secreted 
by the small buccal glands. It is destined to lubricate the ali- 
mentary bolus and to facilitate its passage through the isthmus 
of the fauces and the esophagus. 

In the second place, they contain numerous closed or duct- 
less follicles, which are situated in the deeper layers of the 
tonsil ; and in this respect they resemble other ductless or 
(524) 



TONSILITIS. 525 

blood glands, such as the lymphatic ganglia, the spleen, the 
thymus, etc., and, like them, they modify notably some of the 
constituents of the blood, and aid in the formation of the white 
corpuscles. The tonsils are, however, from a functional or 
physiological point of view, merely adjuncts of other organs, 
and bear but a minor part in the elaboration of the blood, and 
hence their extirpation does not lead to any serious disturbance 
of nutrition or materially affect the general health. It is in the 
bottom of the lacunae, above mentioned, that those cheesy 
masses are formed which are so offensive in certain inflamma- 
tions of the gland. These cheesy masses sometimes become 
hard and transformed into calculi. The tonsils are very prone 
to both acute and chronic inflammation. In the latter case, the 
inflammation nearly, but not quite always, results in more or 
less hypertrophy or enlargement of the gland. 

In acute tonsilitis, occurring in early childhood, there does 
not seem to be the same tendency to suppuration that obtains 
later in life. I do not think I have ever seen a case of suppu- 
rative tonsilitis in a child under the age of puberty. 

In childhood and youth tonsilar inflammation is very com- 
mon, but not so common as in early adult life. It is rare in 
infancy, although enlargement of the tonsils is very frequently 
met with, even in very young infants. 

Temperament seems to have much to do in the production 
of acute inflammation of the tonsils. It is most common 
among pale and lymphatic girls and boys. Enlargement or 
hypertrophy of the tonsils is very conducive to inflammation 
of these organs, and one attack renders the patient more liable 
to a recurrence. Such persons are very liable to sore throat 
from the slightest disturbance of stomach or bowels, or any un- 
due exposure to cold or dampness. Tonsilitis is much more 
prevalent in seasons of rapid changes of temperature, such as 
are common in our variable climate during the spring and 
autumn. It is also a well-known fact that tonsilitis is more 
prevalent when measles, scarlatina and diphtheria are also pre- 
vailing. Among the direct causes of tonsilitis, the principal 
ones are undoubtedly the influence of cold and wet acting 
locally on the neck or feet. Sitting in a draught when warm 
and perspiring, getting the feet damp, neglecting to change 
the clothing after getting it wet ; these are unquestionably the 
most prolific causes of the disease. 

Indirectly, certain atmospheric and local conditions probably 
predispose to tonsilitis, and the same may be said of septic in- 
fluences, such as bad sewerage and the vitiated atmosphere of 
illy-ventilated homes. It is said by Kingston Fox that the dif- 
ferential diagnosis from acute tonsilitis, due to cold or other 



526 THE DISEASES OF CHILDREN. 

simple causes, is made by the fact that the septic cases are 
bilateral in the beginning, while the others are unilateral, as a 
rule. There is so much evidence that bad sanitary influences 
participate in the causation of tonsilitis, that whenever a child 
is continually complaining of his throat, and the tonsils are the 
seat of repeated attacks of inflammation, it is almost certain 
that a careful inspection of the apartments will disclose the 
cause in defective drainage, or other unsanitary conditions. It 
goes without saying that when this is the case the producing 
cause must be removed before the child can be made perma- 
nently well, and future attacks averted. 

Symptoms. — For convenience of description, tonsilitis may 
be divided into acute and chronic, the latter being attended 
with more or less permanent hypertrophy of the gland. 

In the acute variety, the inflammation often begins with a 
chill, and is always attended with fever, the temperature ranging 
from ioi° to as high as 103° Fahr. There is aching and sore- 
ness of the muscles generally, the same as is experienced in 
the beginning of a severe catarrh. The pulse is rapid and full, 
and the tongue is furred and red at the edges. There is headache. 
The tonsils are swollen and red, and there is much pain expe- 
rienced when swallowing is attempted. An inspection of the 
throat reveals the fact that not only are the tonsils involved, 
but also the uvula, the pharynx and the pillars of the fauces. 
The uvula is not usually swollen at the commencement of the 
attack, but commonly becomes edematous later on. The pain 
experienced in deglutition increases as the disease progresses, 
until the child is afraid or unable to swallow, ^nd any attempt 
to do so produces a muscular spasm, and a return of the fluid 
through the nose. The pain which accompanies deglutition is 
sharp in character, and it shoots up into the ears and side of 
the head. All movements of the jaws are painful. Sing- 
ing or buzzing in the ears is often present, and adds another 
uncomfortable factor to the general suffering. 

At the height of the disease the temperature is often as high 
as 104° Fahr. The skin is usually moist and clammy, and the 
face is anxious, haggard and distressed. 

Fortunately for the patient, the pain and suffering are out of 
all proportion to the gravity of the disease, and after a few days, 
and in mild cases in a few hours, the distress is greatly amel- 
iorated. In some cases, almost at the beginning, and in others 
after the lapse of a day or two, there is seen on the tonsils 
scattered spots or flecks of exudate from the lacunje, each spot 
marking the orifice of one of the ducts. These exudations are 
grayish in color, and are often mixed with a glairy mucus, 
which covers to a greater or less extent the surface of the tonsil, 



TONSILITIS. 527 

but does not dip into its recesses and become firmly adherent, 
like the exudative patch seen in diphtheria. Indeed, the filmy 
exudate which occurs in tonsilitis can be wiped off with a camel's- 
hair brush, and does not leave a raw, ulcerated, or bleeding 
surface underneath it. When there is considerable swelling 
of the tonsils, the voice is thickened, and assumes a character- 
istic nasal intonation. Besides the exudation on the tonsils, all 
of the muciparous glands of the mouth take on increased ac- 
tivity, and viscid, stringy mucus collects in the throat, which is 
expectorated with difficulty, and by very young children is 
swallowed. In cases where the disease is distinctly follicular — 
that is to say, when the exudate is scattered over the tonsil, 
marking the mouths of the crypts — the constitutional symptoms, 
such as fever, chills, pain and general malaise, are greater than 
in others where the inflammation is more superficial. Some 
authors make a distinction between these varieties — the super- 
ficial or the erythematous ; and the follicular or lacunal ; but 
there is in the writer's estimation little advantage in such a dif- 
ferentiation. The causes are precisely the same ; the general 
symptoms are the same. The only difference, indeed, is that 
in the follicular variety of tonsilitis, the inflammation extends 
into the lacunae, and involves the follicles to a greater extent 
than does the simple or erythematous, and in consequence, the 
fever is apt to be higher, and the other symptoms somewhat 
aggravated. It may be said, however, that in follicular tonsil- 
itis, the exudation is apt to be more cheesy in character, and 
to project out from the follicular orifices, instead of forming a 
slimy or creamy patch over a considerable tonsilar area. There 
is another form of tonsilitis, called the parenchyuiatous or 
suppurative, which occasionally, though rarely, affects children. 
It is more common after puberty, and especially after maturity 
is reached. This is the so-called " quinsy " of the laity. In 
this variety of tonsilitis, all of the symptoms just described are 
intensified. The fever may, perhaps, be no higher, but the ton- 
sils are more swollen ; the pain in swallowing is greater, and 
there is often considerable dypsnea from occulsion of the throat 
from the intensely enlarged glands, which in severe cases nearly 
touch each other in the median line. The inflammation is so 
diffused, and involves to such an extent the pillars of the 
pharynx and the adjacent connective tissue, that it is almost 
impossible for the patient to open the mouth for inspection. 
Quinsy generally begins on one side ; and after a period vary- 
ing from three to five days, the opposite tonsil becomes in- 
volved. Where both tonsils are affected from the beginning, 
there may be great difficulty in breathing, and the general dis- 
tress be very great. After the disease has run a course of from 



528 THE DISEASES OF CHILDREN. 

five to seven days, a yellowish spot can sometimes be seen on 
the reddened and glossy surface of the gland, showing where 
the pus is most superficial. At this point the abscess will soon 
burst and a quantity of pus be discharged. As soon as this 
occurs, immediate relief is experienced ; the fever abates, and 
in a few days the whole trouble is over. 

Course and Duration. — Tonsilitis varies greatly in its course, 
gravity and duration. In its simplest form it may be so mild 
as to attract but little attention. A slight soreness of the 
throat, lasting for twenty-four or forty-eight hours, with but 
little fever and no constitutional symptoms, may constitute 
the whole attack. In cases of average or moderate severity, 
the duration of marked symptoms is from three to five days. 
When the inflammation of the tonsils goes on to suppuration, 
the duration is longer, for although it is unusual for both ton- 
sils to suppurate during the same attack, it is quite common for 
the inflammation to extend to the opposite side, and in this way 
to prolong the disease. An attack of quinsy is rarely recov- 
ered from in less than from ten days to two weeks. 

Abscess of the tonsils usually points anteriorly towards the 
buccal cavity, but in rare instances it has been known to evacu- 
ate itself posteriorly. While the abscess is in process of forma- 
tion, the pains are of a lancinating character, and are accom- 
panied by well-marked rigors. In children who have suffered 
from tonsilitis repeatedly, the glands are usually permanently 
enlarged. 

Diagnosis. — The only trouble likely to be experienced in 
properly diagnosing tonsilitis is in distinguishing the follicular 
variety from a mild diphtheria. Sometimes this is extremely 
difficult. The exudation, which at first distinctly marked the 
orifices of the lacunae, sometimes coalesces, and forms a consec- 
utive patch of membrane that closely resembles the diphthe- 
ritic pellicle. If seen early in the attack, the diagnosis is 
simplified, for the exudate is then scattered and is whiter, 
while the exudate is more elevated or punctated. It is easily 
removed from the surface by means of a throat probang 
or brush, w^hile the diphtheritic deposit is more gray, more 
adherent, and tougher, and, if forcibly removed, leaves behind 
a raw and bleeding surface. There is sometimes but little dif- 
ference in the foulness of the odor that proceeds from the 
mouth in the two diseases. While that of diphtheria is usually 
more pungent and fetid, we have seen cases of tonsilitis where 
the breath was equally foul. 

In determining the precise nature of a tonsilitis, we may 
have to wait until we can observe, for a few hours at least, the 
course and behavior of the exudation. That of diphtheria is 



CHRONIC TONSILITIS. 529 

more rapid in its spread, and if it be detached, is rapidly repro- 
duced. Dr. Lennox Browne has called attention to one point 
of differentiation between lacunal tonsilitis and diphtheria, 
which is of great practical help in doubtful cases, and so far as 
our own experience goes, it is a point well taken. He says : 
^* The membrane in tonsilitis is limited to the tonsils themselves, 
whereas in diphtheria it is extremely rare not to see patches at 
the same time on the uvula and the soft palate." 

Prognosis. — Except in extremely rare cases, the prognosis is 
always good. This statement, however, refers to the hazard to life 
only. Children of a debilitated and strumous constitution are 
much pulled down by it, and the outlook into the future is the 
more grave, because one attack is quite certain to be followed 
by others, and this tendency increases with every fresh out- 
break. 

Treatment. — The remedies which will be found of most value 
in the treatment of tonsilitis are belladoniia, kali bicJiromicuin^ 
tartar emetic, and mercurius. In the milder form, and at the 
beginning of an attack, where there is intense redness, pain and 
tenderness, bell, will meet all the requirements of the case. 

Where the exudation is considerable, and the mouth is filled 
with a viscid, glairy, stringy mucus, kali is to be preferred. In 
cases where the indications warrant it, the two remedies may 
be given in alternation. Mercurius biniodide is useful in cases 
where there is swelling of the external cervical glands, and out- 
side tenderness in connection with the internal trouble. Apis 
mel. is indicated when the tonsilitis is of the superficial, or 
erythematous variety, accompanied with puffiness of the uvula, 
which looks like an inflated bladder, or a bag of jelly. Hepar 
sulph. is of value when suppuration is inevitable, but delayed. 

The inhalation of steam is always grateful, and may be medi- 
cated with apple-vinegar or permanganate of potash, if there is 
much fetor to the breath. Cloths wrung out of hot water, or 
hot flaxseed poultices applied to the outside of the neck, will 
hasten suppuration where this cannot be avoided, and shorten 
the duration of suffering. As soon as a point is discovered 
where the abscess is disposed to break, a sharp-pointed bistoury 
should be used ; the blade, all but its tip, having been pre- 
viously wrapped with adhesive plaster in order to limit the 
depth of the incision. 

CHRONIC TONSILITIS (HYPERTROPHY OF THE TONSILS). 

This form of tonsilitis differs in many material respects from, 
that which we have just considered. Repeated attacks of acute 
tonsilitis may, indeed, leave these glands hypertrophied, but 
D. C— 34 



530 THE DISEASES OF CHILDREN. 

this is not always the case ; the acute inflammation often hav- 
ing precisely the opposite effect, and leaving them shrivelled 
and atrophied. 

Chronic hypertrophy is generally insidious in its approach 
and progress, and does not necessarily imply previous attacks 
of acute inflammation. It is sometimes congenital, or shows 
itself so soon after birth as to leave little ground to doubt of 
its hereditary origin. 

This view of its etiology is confirmed by the family history, 
for it will be often found that other members of the family have 
suffered in the same manner, and very likely the parents will 
tell you that they themselves were thus afflicted in their early 
childhood. Some observers have endeavored to trace a con- 
nection between chronic tonsilitis and struma or rickets, but 
such efforts have not been substantiated by extended observa- 
tions. Many cases will be met with where the tonsils are 
notably enlarged, and where there is a total absence of other 
indications of ill-health. In most cases chronic hypertrophy is 
of trifling import, or would be so but for the tendency, which 
is well marked in all cases, of predisposing to inflammations of 
these same organs of an acute and more serious character. 

Once chronic enlargement of the tonsils has been established, 
every trifling disturbance of system or accidental exposure to 
cold, is sufficient to determine a new and acute inflammation, 
not of these glands alone, but of glands adjacent, and of the 
mucous membrane of the pharynx as well. In infants thus 
affected, the process of teething is frequently attended with 
more than the usual disturbances, and scarlatina and diphtheria 
are both apt to be complicated, if not encouraged, by this con- 
dition of chronic hypertrophy. The causes of this affection, 
aside from hereditary influence already referred to, are obscure. 
Delicate children with thick lips, and gross, ill-formed features, 
suggestive of the strumous constitution ; and children who are 
particularly subject to disorders of digestion, are the favorite 
victims of chronic tonsilitis; and so are the children of the poor 
who live in basements, and who breathe a vitiated atmosphere, 
living upon poor and insufficient food, and deprived of suffi- 
cient sunlight. Tonsilar enlargement may manifest itself at 
any time succeeding birth, but is most commonly observed 
between the ages of two and ten years. Occasionally the child 
reaches puberty before attention is called to the disorder, and 
then it is quite naturally associated with sexual development. 
As regards sex, it is noticeably more frequent in boys than girls. 
The duration of chronic enlargement of the tonsils is indefinite. 
Some children undoubtedly outgrow it, owing to a better state 
of the general health, while the changes which take place at 



CHRONIC TONSILITIS. 531 

puberty often exercise a salutary influence, and stop the in- 
crease, if they do not effect a permanent resolution. Indeed, 
in the majority of cases, after puberty the affection ceases to 
be a disease of importance, or to cause any special annoyance, 
for even if the tonsils are not materially diminished in size, the 
increased dimensions of the throat and fauces give more room, 
and thus relieve any discomfort there may have been. 

It is stated by Bosworth that true hypertrophy of the ton- 
sils never disappears, except by excision, and has a far greater 
tendency to increase than to remain in statu quo. The extent 
to which hypertrophy may go is very variable. In extreme 
cases the tonsils are so much enlarged that they touch the 
uvula on either side, and when this is the case the breathing 
is seriously interfered with. Usually the enlargement is only 
moderate in extent, and does not interfere seriously with 
respiration. It does, however, interfere with free vocaliza- 
tion and gives a nasal twang to the voice. Chronic coryza 
is frequently associated with chronic hypertrophy of the 
tonsils. When this condition of the tonsils exists, the glands 
are not only enlarged, but indurated. They have the appear- 
ance of Hght red or pink tumors, and if due to, and asso- 
ciated with, frequent attacks of acute inflammation, their 
surfaces are studded with depressions, or small excavations, 
rendering them uneven or somewhat honeycombed from rup- 
tured folHcles or congested and enlarged lacunae. In other 
cases the surface is smooth and glistening. When pressed 
upon by the finger, the glands give a sensation of firmness and 
elasticity, which is due to the fact that the interfollicular 
and deep fibro-cellular tissue is increased. In rare cases, only 
a single tonsil is involved in chronic hypertrophy ; more often 
both are similarly enlarged, although one may be more so than 
its fellow. The symptoms of enlargement of the tonsils are 
usually so apparent as to be unmistakable. If the enlarge- 
ment is considerable, it causes the child to snore ; it modifies 
the voice ; and produces a frequent cough, and occasionally 
gives rise to deafness by the pressure on the eustachian tubes, 
and the associated hypertrophic or inflammatory changes 
which it invites in the surrounding mucous membrane. In 
some cases it so obstructs respiration as to distort the chest, 
which becomes " pigeon breasted," from the failure to prop- 
erly inflate the lungs, and so oppose the influence on the ribs 
of outside atmospheric pressure. 

Treatment. — The treatment of chronic hypertrophy of the 
tonsils is not very satisfactory. Whether this is due to the 
inefficiency of remedies, or to the lack of persistence in their 
employment, is an open question. In bad cases, undoubtedly 



532 THE DISEASES OF CHILDREN. 

excision is the only reliable remedy, and time is wasted in pro- 
crastination. The fact that the disease is never fatal, and 
that as age advances there is a chance of spontaneous im- 
provement, renders parents very repugnant to an operation 
that may be postponed or in course of time become un- 
necessary. 

As the victims of the disease are generally weak and physi- 
cally ill-favored, the first efforts given to amelioration or cure 
should be addressed to the general health. 

The sanitary surroundings of the patient should be improved, 
and fresh air and sunshine recommended. The diet should be 
wholesome and nutritious. To children of the strumous habit, 
cod-liver oil should be given, with daily baths of salt water 
moderately cold, with brisk general frictions of the entire body. 
Everything should be done to improve the general health. In 
addition to this, it is said that much good maybe accomplished 
by teaching the child to press upon the tonsils with the finger 
for a few minutes daily. In infants and young children this 
may be done by the mother or nurse. We have never had 
much success with local measures, such as painting the tonsils 
with iodine or astringent lotions. 

We have had good results in some cases with the internal ad- 
ministration oi fucusves., given in tincture of one to three drops 
three times daily, in sweetened water or on sugar. We have 
also seen good results in a few cases from calc. iod. jx and 
mere. iod. jjtr, given thrice daily, and kept up for many weeks. 
Where the chronic hypertrophy is accompanied with a dis- 
charge of cheesy and offensive matter from the tonsilar follicles, 
kali biehromicum is a useful medicine. Arndt and others speak 
highly of baryta earb. and baryta iodatus. 

RETRO-PHARYNGEAL ABSCESS. 

A very infrequent but occasionally occurring disease some- 
times attacks the submucous tissues of the pharynx, and is at- 
tended with inflammation which results in the formation of 
pus. It is a disease that may occur at all ages, but is most 
commonly met with in young infants. In some cases the cause 
is traumatism, and follows a wound from swallowing bones, 
pins or other foreign substances. At other times the disease is 
idiopathic, and is due to cold affecting scrofulous or syphilitic 
subjects. The symptoms are not always well defined, and may 
be mistaken for those of enlarged tonsils. There is deep-seated 
pain in the pharynx, which is especially noticeable when swal- 
lowing is attempted. The neck i's stiff, and the head is held on 
one side in a peculiar and fixed position. There are spasmodic 



RETRO-PHARTNGEAL ABSCESS. 533 

attacks of dyspnea, and sometimes there are convulsions. 
When the disease is idiopathic, it may develop in the course of 
forty-eight hours ; but when it is secondary to scarlatina or 
acute pharyngitis, it generally takes from seven to ten days to 
develop. When occasioned by caries of the spine, its progress 
is still more slow and indefinite. The first noticeable symp- 
toms are pain on deglutition, which becomes more pronounced 
as the disease progresses, until, if the abscess be large, swallow- 
ing is rendered impossible. An inspection of the throat re- 
veals a round, bulging tumor in the fauces, which is firm and 
elastic to the touch. Sooner or later distinct fluctuation will 
be present, and as soon as this is apparent there should be no 
delay in opening the abscess and evacuating its contents. This 
is imperatively demanded, for if the abscess be permitted to 
open spontaneously, it may happen at inopportune times, as 
when the child is asleep, and pus be sucked into the lungs, 
causing death from suffocation. The incision should be verti- 
cal, with a guarded bistoury, all but the point being encased in 
strapping. 



CHAPTER V. 

LARYNGITIS (SPASMODIC CROUP, FALSE CROUP, CATARRHAL 

LARYNGITIS). 

Spasmodic Laryngitis. — This affection of the larynx is 
most frequently met with in children during first dentition, and 
especially during the second year of life. It is common, also, 
up to six or seven years of age, and the tendency to it some- 
times persists till the fifteenth or sixteenth year. Like other 
inflammatory affections of the air-passages, it is most common 
during the cold months, and in changeable weather. It some- 
times accompanies the eruptive fevers, and also bronchitis and 
pharyngitis. In the latter case it is due to an extension of the 
primary inflammation downward. Its remote causes are gas- 
tric derangements and heredity. Some families are very prone 
to it ; and some children are subject to repeated attacks. We 
have a case in mind of a child who, from two to six years of 
age, had an attack of spasmodic croup whenever the wind veered 
around suddenly and blew from the east. The exciting cause 
is usually a sudden chilling of a portion of the body, or expo- 
sure to dampness and cold. It sometimes has no prodromal 
symptom, coming on suddenlj^ toward midnight, after several 
hours of natural and undisturbed sleep. 

More often, however, the attack is preceded by more or less 
coryza, and by hoarseness, which is apparent when the child 
cries, or if old enough, when it attempts to speak. Occasion- 
ally there is complete loss of voice, so that speech above a 
whisper is impossible. There may have been some cough dur- 
ing the preceding day, which tightens up as night approaches. 
But in a typical case, the child goes to bed without fever or 
anything in the way of ill-health to attract attention. After a 
short sleep, it awakens with a shrill, ringing cough, which is 
variously described as " brassy," or " clanging." There is more 
or less oppression about the chest, and difficulty of breathing. 
Inspiration is prolonged, stridulous, and crowing. The child 
exhibits fear and anxiety, wishes to be taken up, and if the 
breathing is much impeded, breaks out into a cold perspiration. 
If an attempt be made to speak, it is found that the voice is 
lost, and only a whisper remains. The dypsnea is often very 
great, but the gravity of the symptoms is out of all proportion 
(534) 



CHRONIC LARYNGITIS. 535 

to that of the disease itself. The difficulty is manifestly spas- 
modic, for often the child will soon be appeased, the spasm 
passes away, and he drops off into a quiet sleep, which is inter- 
rupted again and again at variable intervals by a repetition of 
the "croupy cough." If left to itself, this experience will be 
repeated on the two suceeding nights, for spasmodic laryngitis 
inclines to run a course of three days. During this time the 
cough remains croupy, but gives but little trouble during the 
daytime. At the end of from three to five days, or sooner, 
the voice is quite restored, the cough disappears, and the child 
is quite well again. 

Diagnosis. — The only disease that could be confounded with 
spasmodic laryngitis is that more formidable disease, to be de- 
scribed later on, viz.: true croup. In most cases, however, 
there need be no confusion. The sudden onset of the attack; 
the previous coryza; the absence of persistent inspiratory 
stridor, and the speedy subsidence of the momentary fear and 
restlessness, indicating a passing spasm, will serve to show that 
the disease is a transient and trivial disorder, and not one im- 
periling life from suffocation. This differential diagnosis will 
be made more plain when speaking of the graver disease. 

Treatment. — These attacks frequently pass off after the usual 
exhibition of domestic remedies, one of the best of which is a 
half-teaspoonful of warm vaselin. This seldom fails to give 
prompt relief from the immediate spasm, and other and more 
scientific treatment can then be given to anticipate or prevent 
the attack on the succeeding night. As a prophylaxis, the 
child who is subject to spasmodic croup should be warmly clad 
and be kept in a warm, dry, sunny atmosphere. 

While the attack is present, the child should be kept in bed in 
a warm room, and if the attack is at all obstinate, the air should 
be moistened with a steam atomizer or a bronchitis kettle. 
Flaxseed poultices or hot fomentations applied to the throat 
"will help to shorten the paroxysm and prevent a speedy repe- 
tition. 

In the matter of internal remedies, Boenninghausen's aconite, 
spongia and hepar sulphur are famous the world over. Few 
cases will be found to resist them. The latter alone will often 
be found quite sufficient. Kali bichromicum, ipecac, tartar 
■emetic, bromin and sambucus are also remedies that have their 
advocates, and may be used according to their indications. 

Chronic Laryngitis is of very rare occurrence in child- 
hood, and when it does occur, it is generally of syphilitic origin. 

There is persistent hoarseness, sometimes amounting to 
aphonia. There is lacking the fever attendant upon acute 



536 THE DISEASES OF CHILDREN. 

laryngitis, but otherwise the symptoms are similar, but of less 
severity, except as an acute attack is grafted into the chronic 
condition. When this is the case, the child is placed in great 
peril, and tracheotomy or intubation frequently offers the only 
recourse. There is always danger in these cases of permanent 
thickening of the laryngeal tissues, and of warty growths within 
the larynx. The treatment, aside from relieving the dyspnea by 
measures already mentioned, should be addressed to the dys- 
crasia underlying the local disease, as laid down under the 
head of Infantile Syphilis. 

Laryngeal Spasm— Laryngismus Stridulus.— In addi- 
tion to the laryngeal affections already mentioned, there is one 
occasionally met with in which there is no inflammation, and 
no local lesion discernible, and yet it is accompanied with 
great dyspnea and catching of the breath, and may even prove 
fatal. It is often associated with rickets, but may occur idio- 
pathically. It is to all intents and purposes a nervous or spas- 
modic affection of the larynx, and involves more especially the 
glottis and epiglottis. 

As Edmonds says, *' It might with much propriety be called 
an asthma of the larynx." It is sometimes spoken of by 
authors and the laity as " internal convulsions." 

The essential feature of the disease consists in the child hold- 
ing its breath, or being unable to catch its breath, until the 
face becomes livid and suffocation seems inevitable. West thus 
describes an attack : '' The child throws its head back, its face 
and lips become livid, or an ashy pallor surrounds the mouth, 
and slight convulsive movements pass over the muscles of the 
face ; the chest is motionless and suffocation seems impending. 
But in a few moments the spasm yields, expiration is effected, 
and the crowing inspiration succeeds." 

The crowing sound which thus terminates these attacks has 
given the disease the vulgar name of *' child crowing." 

The spasm is essentially reflex in its nature, and is frequently 
caused by some irritation of the mediastinal nerves. It is 
brought on by sudden excitement, or anything which hurries 
the breathing. The attack is associated with a sort of wheeze, 
which is something between the whoop of pertussis and the 
stridor of true croup. The attack may not last more than a 
minute, or even less, and the crow over, there is perhaps a fit 
of crying, when the child drops to sleep or goes on with its 
play as if nothing had happened. In some of these cases, there 
has been found to be an enlargement of the bronchial glands, 
but this is by no means uniform. The causes of laryngismus 
are various. It is so often associated with rickets that some 



LARYNGEAL SPASM. 537 

writers have stated that there is never one of these diseases 
without the other. This is certainly a mistake, for we have 
seen at least three cases in our private practice in which there 
was not the slightest indication of rickets. 

Goodhart considers that this affection, or one quite analo- 
gous to it, which he calls '' infantile spasm of the larynx," is 
due oftentimes to a " congenital recurvation of the epiglottis, 
which is a common thing in infancy and early childhood." 
Whatever the cause operating in a given case, the affection 
is not attended with the real danger that the symptoms indi- 
cate. When due to, or associated with, general convulsions, 
there is genuine danger, for there is not in such cases the same 
response to stimuli that is present when convulsions are ab- 
sent. In most of these cases the spasms are ultimately out- 
grown, or disappear as the child becomes older, for the disease 
is purely infantile in its expression. 

Treatment. — When laryngismus is associated with rickets, or 
enlarged bronchial glands, the treatment must have reference 
to the constitutional dyscrasia. Change of air, a sojourn at 
the seaside, cod-liver oil, calc. pJws., and remedies already men- 
tioned under the head of Rickets, will be of service. For the 
rehef of the spasm itself, the inhalation of some quick acting 
stimulant is required. Nitrite of amy I, chloroj-onn or aromatic 
spirits of ammonia will answer the purpose. For internal 
administration, with a view of breaking up the habit and pre- 
venting a repetition of the spasms, belladonna, hyoscyamnSy 
cuprum and especially gelsemium, will be found of value. 



CHAPTER VI. 

ACUTE MEMBRANOUS LARYNGITIS (PSEUDO-MEMBRANOUS 
LARYNGITIS) ; TRUE CROUP. 

This form of laryngitis, commonly known as *' membranous 
croup," differs from all other forms of laryngeal inflammation 
in being characterized by the formation within the larynx or 
trachea of a fibrinous pseudo-membrane. It occurs most fre- 
quently between the ages of two and twelve, but no age is com- 
pletely exempt from it. It is rarely met with under six months 
of age, and is not common after puberty. 

It is one of the most fatal of infantile diseases. 

This form of laryngitis is so often associated with diphtheria 
that many authors refuse to consider it as having other than a 
diphtheritic origin. It is conceded on all hands that the diph- 
theritic membrane may originate in the larynx, or the trachea, 
without showing any exudation on the tonsils or on the fauces, 
and that many cases of croup are genuine cases of diphtheria. 
In other words, no one disputes the fact that there may be, and 
are, many cases of diphtheritic croup in which there are no 
other visible evidences of the disease than are afforded by the 
croupy manifestations. 

When diphtheria has once manifested itself in the pharynx, 
and thence extended into larynx ortrachea, there can be no ques- 
tion as to the nature of the inflammation there set up. But 
when the primary disease is below the epiglottis, and when 
there is an entire absence of any history of exposure to the 
diphtheritic contagium, the case is different. It is in such cases 
that the question arises — Is there such a thing as membranous 
laryngitis independent of diphtheria ? Our own answer to the 
question is emphatically in the affirmative. We recognize two 
distinct and separate forms of croup — the specific and the non- 
specific ; or, lest our words may be misunderstood, a diptheritic 
and a non-diphtheritic croup. Let the grounds for this belief 
be briefly stated. In the first place, it is a well-established fact 
that inflammation of the laryngeal and tracheal surface, when- 
ever it reaches a certain grade of severity, is very sure to be 
attended by the exudation of fibrin and the formation of a 
pseudo-membrane. This has been repeatedly observed in cases 
of inflammation in these localities produced by the inhalation 
(538) 



ACUTE MEMBRA NO US LAR TNG I TIS. 539 

of superheated steam, or hot smoke. Surely in such cases there 
could be no suspicion of specific origin. Then, again, we see 
cases of croup, with all its attendant phenomena, as a compli- 
cation in measles, pertussis, scarlatina, and even in typhoid 
fever, when there is no indication whatever that there is a diph- 
theritic element present. The clinical history of the two dis- 
eases fails to bear out the theory that they are in any sense 
identical. 

Diphtheria is adynamic or asthenic from the beginning, while 
croup becomes so only towards the termination of fatal cases. 
The one is contagious, the other is not. 

Membranous croup always begins with decided laryngeal 
symptoms, and the attendant exudation is by preference in the 
larynx. If in membranous croup there be a visible exudate in 
the pharynx, or on the soft palate, or uvula, it is from an ex- 
tension of the membrane upwards. 

In diphtheria the membrane exhibits a preference for the 
pharynx, and it is generally, nearly always, hours or days be- 
fore the exudation involves the larynx. 

Diphtheritic croup is, therefore, a secondary affection, while 
true membranous croup is a primary one. 

Diphtheria occurs endemically or epidemically, while croup is 
usually sporadic, affecting only here and there an individual 
and showing no contagious or infectious properties or tenden- 
cies. But the reader is referred to the chapter on Diphtheria, 
where the essential features of the two diseases are placed side 
by side in tabulated form. We cannot see how any unpreju- 
diced mind can fail to«discern the wide difference between the 
two in all essential particulars, or refuse to admit that there is a 
croup which is a local disease, non-specific, and quite distinct 
from the croup of diphtheria. It is with this latter that we 
have now to deal. 

True croup is a disease of childhood rather than infancy, and 
yet infants are by no means exempt from its ravages. It is 
more common after the first year than before, and boys are 
said to be more often affected than girls, in the proportion of 
three to two. It is more prevalent in winter and spring than 
in summer and autumn. 

A cold, damp wind, especially if from the east or northeast, 
greatly favors it. Unlike catarrhal or false croup, true croup 
does not tend to recur. Stiener, who has had an experience 
covering 100,000 cases, states that he has never known the dis- 
ease to occur twice in the same individual. All clinical expe- 
rience tends to show that the exciting cause of the disease is 
exposure to cold and dampness. 

Symptoms. — The early symptoms of true croup are insidious. 



540 THE DTSEASES OF CHILDREN. 

The child may have a croupy cough for several days before 
there is any marked dyspnea; but a slight hoarseness or huski- 
ness of voice, that is scarcely noticeable at first, increases from 
day to day, or perhaps from hour to hour, until, if unrelieved 
by medical treatment, there is complete aphonia. 

In the early stages there is no fever to speak of, and the 
child plays about as usual during the day. At night, however, 
its sleep is disturbed by a ringing bark of a cough, which has a 
decided metallic or brassy sound. This cough recurs at irregu- 
lar intervals, and there is a steady but slow progression of the 
hoarseness. There is a marked tendency to aggravation at or 
just before midnight, in this respect resembling simple or ca- 
tarrhal laryngitis. In some cases the fauces are injected, either 
from the effects of the cough or from diffuse inflammation. As 
the disease progresses, the respirations become noisy and la- 
bored, the face becomes flushed and takes on a look of anxiety. 
An inspection of the chest will reveal the fact that at each 
inspiration the post-clavicular, supra-sternal and infra-mammary 
regions are depressed. The breathing becomes audible, and 
has a sawing sound that may be heard at a considerable dis- 
tance. There is usually no coryza in these cases. On the con- 
trary, the throat and nasal mucous membranes are usually dry 
and somewhat injected. Sometimes the redness is slight and 
sometimes quite marked. On the second or third day, the 
disease progressing all the time, the dyspnea increases, and 
there is some febrile movement, although at no time is the 
temperature high. 

When the obstructive membrane in the larynx or trachea has 
reached a certain stage, the appearance of the child is very 
characteristic. Distress is pictured on every feature. The eyes 
stare ; the face is red or by turns purple. The inspirations 
are prolonged, and decidedly stridulous. The child clutches at 
his throat, as if with his fingers he could aid his struggles for 
breath. Every effort at coughing produces a characteristic 
ringing sound, which, after a time, loses volume, until it is lost 
in a wheeze or becomes inaudible. The attacks of dyspnea are 
paroxysmal, and may last for a few moments, or in exceptional 
cases, for a half-hour or more. There is manifestly a recurrent 
spasm of the glottis, which adds to the distressful breathing. 
There is great restlessness after the respirations have become 
seriously embarrassed. The child is constantly changing posi- 
tion and place — now wanting to be carried, and now to be put 
back to bed. At intervals, suffocative attacks occur, when 
•asphyxia seems to be inevitable. The inability to carry on the 
respiratory function at last produces its inevitable result, and 
the blood becomes loaded with carbonic acid. This is evi- 



ACUTE MEMBRANOUS LARTNGITIS. 541 

denced by the blueness of the Hps, the pallor of the face, and 
the dullness of the sensibilities. The expression of the face 
loses its anxiety and fear, and a look of dullness and indiffer- 
ence takes their place. The respirations are more quiet and 
superficial. The stridor disappears, but there are frequent 
struggles for breath, followed by exhaustion and a lapse into a 
comatose or semi-comatose condition. 

Dr. J. S. Mitchell, in his able monogram on this disease, 
published in Arndt's "System of Medicine," says under the head, 
Special Symptoms — Breathing: "The peculiar breathing of 
croup, which gives it its distinctive character, and which has 
the sound which is most dreaded by the parents and physician, 
is due to the fact that, notwithstanding the labored breathing, 
only a small quantity of air is able to pass through the narrow 
glottis. There is prolonged inspiration, and a wheezing, whis- 
tling snoring sound, sometimes heard for a long distance. It has 
a sibilant, tubular, metallic quality, and its pitch is high. In 
one case which was under my charge, it was scarcely possible to 
find any part of the house so distant that the distressing sound 
could not be heard. The expiration is marked, and accompa- 
nied by the rattling of mucus, and is distinguished from ''■he 
sharper and sawing nature of the inspiratory sound, by its low 
tone and snoring quality. The breathing usually continues to 
manifest these characteristics from the time the second stage 
is reached until the end, or until there has been relief to the 
dyspnea. 

" The respiratory sounds are also distinctive ; they are notably 
deficient, but if, during the prevalence of dyspnea, they become 
increased in frequency, they are not effective. The supra-clav- 
icular spaces are depressed during inspiration ; the intercostal 
spaces do not bulge, nor do the chest walls expand to the 
normal extent. The inspiratory retraction, w^hich has been be- 
fore noticed, is significant of marked dyspnea. The febrile 
movement is not marked after the first or second day. The 
temperature may rise as high as 102° or 103°, but ordinarily it 
will be found to be about 100°, and on the third, or at least the- 
fifth day, it will subside. In those cases where it is found up 
to 104° or 105 8-10°, we shall find that extensive bronchitis or 
pneumonia exists. The pulse, early, is full, hard, and from 
120 to 130. In the second stage it continues at about this rate, 
except that during the suffocative spells it may rise 20 or 30 
beats ; in the last stage it becomes very rapid, 160, or even 180, 
^mall, compressible, and intermittent. A persistent high tem- 
perature is significant either of diphtheria or catarrhal laryngitis. 

"The dyspnea is one of the evidences of the disease. It is 
the result of the laryngeal stenosis, and marks the advance of 



542 THE DISEASES OF CHILDREN. 

the second stage. The respirations rise from 28 to 32 per 
minute, sometimes more ; all the accessory muscles are brought 
into play. The child throws the head upward with each res- 
piration, somewhat after the manner of the asthmatic. His 
whole efforts are bent on expanding the chest. The inspirations 
grow more labored as the laryngeal contraction increases; the 
mouth is opened widely. The alae nasi now contract, and again 
are widely open ; the larynx is depressed after each inspiration, 
and the cartilages of the lower ribs are drawn inwards. 

" Different opinions have been expressed as to the cause of 
this dyspnea. Niemeyer has advanced the view that it is de- 
pendent mainly upon paralysis of the laryngeal muscles. He 
regards this paralysis as the result of the infiltration of the 
mucous and submucous tissues, which exerts pressure upon the 
muscles and renders them sodden and powerless. An important 
clinical fact is brought out by this consideration, for in paraly- 
sis of the laryngeal muscles inspiration is affected, being ren- 
dered prolonged and stridulous, while the expiration is easy ; 
difficulty in both inspiration and expiration indicates that there 
is an exudation, or a contraction of the glottis from edema. 

'* I once had an opportunity to make a post-mortem exami- 
nation in the case of a child that had died from a severe attack 
of false croup, which, throughout its history of eleven days, 
simulated constantly the symptoms of membranous croup, 
with the exception that there was at no time evidence of exu- 
dation. He had, however, every other symptom characteristic 
of membranous croup. The child died during one of the suf- 
focative attacks. There was no evidence of any membrane in 
the larynx, nor was there any evidence of the severe dyspnea 
to which the child had been subjected ; there was a slight trace of 
edema glottidis, but entirely insufficient to account for the dysp- 
nea and prolonged stridor. The parts were not hyperemic, 
though, of course, this is explained by the well-known fact that 
the laryngeal mucous membrane is rich in elastic fibers, and we 
often find it free from hyperemia after death, when previous 
laryngoscopic examination had shown an intense degree of con- 
gestion. This case of stridor and dyspnea, which was worse 
upon inspiration, was undoubtedly due to inflammatory exten- 
sion, so far affecting the muscles as to interfere with their 
proper action. There was no evidence that the difficulty was 
in any way due to central nervous lesion. 

" Rudnicky * claims that the dyspnea of croup is due to lack 
of coordination of the respiratory movement from nervous irri- 
tation. He insists that there is a special disturbance of the 



* Wirner, Med. Wochenschrift., Nos. 323, 324, 325, 1873. 



ACUTE MEMBRANOUS LARYNGITIS. 543 

nerves, and that it may be outside the larynx. He refers to the 
fact that the branches of the superior laryngeal and recurrent 
nerves have many ganglionic cells, which are provided before 
their separation into muscular subdivisions. They are true 
ganglia, from which distinct bands of nerve fibers may extend 
to the muscular layers of the larynx. Rudincky contends that 
Niemeyer's theory is not correct, as was evidenced from laryn- 
goscopic examinations which he made, demonstrating that the 
vocal cords move as usual during the existence of croup, thus 
showing that there could be no paralysis. Ziemssen (vol. iv., p. 
242), regards the dyspnea of croup as the combined result of 
several causes, acting together or in succession, the most com- 
mon of which is, undoubtedly, a mechanical one, namely, the 
swollen, relaxed and intensely-congested state of the mucous 
membrane of the larynx, on the one hand, and the false mem- 
brane and muco-purulent secretion on the other. He says that 
everyone who has had frequent opportunities for observation 
after death of the anatomical changes in the larynx of children, 
and who considers how little is needed to block up the glottis 
in such patients, must be justified in inferring the intimate 
causal connection between the dyspnea of croup and the 
changes referred to. He cites cases in which the most marked 
dyspnea is observed in children during life, without any croup- 
ous membrane being found after death, and in which the ana- 
tomical changes are out of proportion to the symptoms of the 
stenosis ; he states that in more than one hundred cases of fatal 
croup among children, he has been always able to find the false 
membrane in the larynx, though, of course, more intensely and 
more widely developed in some cases than others. But the sin- 
gle case to which I have just referred, shows that a fatal dysp- 
nea may obtain without the presence of slightest amount 
of exudation. This shows that even in true croup it is not 
necessary that the exudation must be the sole cause of the 
dyspnea, and we may reasonably believe that if we can control 
the edema and the spasm of the glottis, we may apprehend 
comparatively little danger from the exudate, unless its quan- 
tity be so great as to completely fill up the larynx. 

"In one case, which I had the opportunity of examining 
through the kindness of Dr. S. P. Hedges, the larynx was com- 
pletely filled with a tough, fibrous exudate, so that it would 
apparently have been impossible for the smallest quantity of 
air to enter. Indeed, it seemed as if the exudate and laryngeal 
structures were simply one solid mass. 

"A therapeutic hint may be obtained here. The treatment 
undoubtedly should be directed more specially to the stenosis, 
with the presumption that it is the result of the edema of the 



544 THE DISEASES OF CHILDREN. 

glottis and spasm of the glottis, rather than of the presence of 
the exudate. It is a well-known fact that after tracheotomy, 
the dyspnea sometimes continues as urgent as before, the lar- 
ynx being then no longer a portion of the respiratory apparatus. 

''Remissions. — These occur in those cases of croup which are 
characterized by a moderate course. There are instances where 
distinct remissions occur in the second stage. There is a 
marked improvement in the dyspnea, although it does not dis- 
appear wholly. There is also a remission of the cough, the 
voice becomes more natural, and we find an improvement in 
the general condition of the patient. The febrile movement is 
almost entirely gone, and the appetite partially or wholly re- 
turns, and there is a disposition to sleep. These remissions are 
very favorable, especially when they are attended by an exfo- 
liation of a certain portion of the false membrane, which may 
be thrown off in small masses mingled with mucus, or in irregu- 
lar masses, sometimes in the form of tubular casts of the part. 
If these exfoliations continue, the remissions indicate that there 
will probably be a favorable termination of the disease, there is 
a longer period between the suffocative spells ; and the dyspnea 
is markedly diminished. The cough grows looser, and the ex- 
pectoration of mucus, or a muco-purulent secretion mixed with 
the flakes of fibrin, increases. The voice becomes less and less 
hoarse, and the fever stops entirely, perspiration occurs, the 
patient becomes more cheerful and natural, and the case turns 
into one of simple laryngeal catarrh. 

*' But many times these remissions are delusive; the suffoca- 
tive attacks occur after the remissions, being more severe than 
before. There is now a fresh exudation occurring, or a spasm 
of the glottis, or of the laryngeal muscles, which has given rise 
to it, and the dyspnea is increased through the special influences 
which are at work, and instead of the remissions, we have a 
disposition to pass into the stage of asphyxia, which is followed 
by a fatal termination of the case. 

" Coinplicatio7is. — The most frequent complication is bronchial 
catarrh, but the diagnosis of its degree is exceedingly difficult. 
It has been found that the sibilant and sonorous rales, together 
with the pronounced mucous sounds, disappear immediately 
after the performance of tracheotomy, indicating that the con- 
gestion was simply a temporary one, due to the dyspnea. In 
yet other cases, after a free entrance of air to the lungs has 
been effected, the rales still continue as a very prominent fea- 
ture. In such cases a coincident bronchitis has arisen from 
extension of the inflammatory process, and we may assume 
the existence of fibrinous exudation in various portions of the 
bronchi and bronchioles. 



ACUTE MEMBRANOUS LARTNGITIS. 545 

*'The explanation of Niemeyer (Ziemssen, vol. IV, p. 251) 
seems hardly necessary. His view is that the pulmonary alve- 
oli enlarge, when laryngeal stenosis has obtained, without the 
entrance of a sufificient quantity of air, thus resulting in the 
rarefaction of the air contained in the bronchi and alveoli. This 
rarefied air acts upon the bronchial mucous membrane and 
upon the walls of the alveoli, just as cupping does upon the 
skin, the result being congestion and increased exudation from 
the blood-vessels as the result of the diminished pressure upon 
the walls of the vessels. To our mind, the extension of the 
inflammatory process, as in other forms of catarrh, seems to 
be all the explanation required. Pneumonia occurs less fre- 
quently as a sequence of croup; when it exists, it may occur 
in the lobular form, not so often as a lobar pneumonia. 

''Atelectasis may occur as a result of the asphyxiated stage 
of croup. The portions of the lung involved are usually the 
lower and posterior parts. Before death, their presence cannot 
be recognized readily by physical examination, unless they 
should involve a large portion of the lung, which is not usual. 
The less frequent complications are pulmonary apoplexy and 
gangrene of the lung. It is doubtful if the latter ever obtains 
in a case of true croup ; the instances which have been noticed 
are undoubtedly the result of diphtheritic laryngitis. 

" Course and Terfnination. — Croup ordinarily runs its course 
in from five to ten days. The severest cases of the fulminant 
variety may terminate fatally in from twenty-four to forty-eight 
hours. The full duration is from four to six days. Instances 
are on record in which the exudation of false membrane on 
the mucous surface of the larynx and bronchi continued for 
several weeks. 

" Pathology. — In the first stage of the disease, the main feature 
is an intense hyperemia with its ordinary accompaniments. The 
mucous surface of the larynx is a bright-red color, and is con- 
siderably swollen and puffy. The exudate varies from a very 
thin pellicle, to a thick, firm, tenacious false membrane, which 
may entirely block up the larynx. Its color is a yellowish- 
white, sometimes brown or gray ; it may be blackened from ex- 
travasation of blood ; the transudation of blood may be suffi- 
ciently extensive to render it, in some instances, blood-streaked, 
or dotted with small clots. The exudate is but loosely adher- 
ent to the mucous surface, and may be readily detached ; in 
other instances its attachment to the mucous surface is much 
more firm. It, however, has not the tendency of the diphthe- 
ritic exudate to extend into the mucous tissue, involving the 
mucous and submucous structures. 

" While, as we have already said, this anatomical difference 
D. C— 35 



546 THE DISEASES OF CHILDREN. 

does not warrant us in assuming its non-identity with diph- 
theria, it is, notwithstanding, a decidedly important link in the 
chain of evidence. The disposition of the exudate is to extend 
downwards rather than upwards. The early writers divided 
croup into the ascending and descending, and it is admitted 
that the tendency is manifestly downwards. 

** It is easy to understand how quickly the dypsnea may be 
increased by the presence of the exudation in the bronchioles ; 
even if the amount of membrane in the larynx should not be ex- 
tensive, the cutting off the entrance of air to the alveoli, by 
the filling up of the bronchioles, adds promptly and effectively 
to the amount of dypsnea. 

** The vocal cords are especially prone to be the seat of the 
exudate. A moderate amount of exudation at this point, 
therefore, the subglottic space being quite free, may induce 
dangerous asphyxia. The inner surface of the glottis is gener- 
ally also involved to a marked extent. The tendency of the 
membrane is to reform, which constitutes one of the discourag- 
ing and dangerous features of croup. After the first exfoli- 
ation of the membrane in flakes or threads, or masses of consid- 
erable size, a second formation occurs, and even a third. How 
much this reformation is influenced by the active methods of 
treatment, locally and internally, which have been in use, is yet 
difficult to determine. 

*' Microscopically, the exudation is found to be made up of 
amorphous, or fibrillated fibrin, with numerous young cells. 
Chemically, it is shown to be coagulated fibrin, soluble in al- 
kalies, and particularly in lime-water. 

** Diagnosis. — The early diagnosis is attended with difficulty. 
It is impossible to designate true croup from a severe case of 
infantile laryngitis, or false croup, until the exudation has un- 
mistakably appeared. 

" The difficulty of laryngoscopic examination in children is 
much to be deplored, for if a view of the larynx could be ob- 
tained, an early and positive diagnosis could be made. Some 
of the cases of infantile laryngitis, as in the one already referred 
to, unfortunately present symptoms which render their differ- 
entiation from true croup entirely impossible. On the second 
or third day it is usually possible to make the diagnosis with 
accuracy, if careful attention is paid to all the points. One 
prominent diagnostic feature is, that in pseudo-croup there is a 
much greater amenability to treatment ; there is not, usually, 
so strong a disposition to the continuance of the dypsnea ; it 
is not so intense nor so prominent. In false croup the febrile 
movement is more readily controlled ; there is not as much 
hoarseness, the voice is not as frequently lost, nor as harsh and 



ACUTE MEMBRANOUS LARTNGITIS. 547 

rough. Instead, also, of tending to grow hoarse on the sec- 
ond or third day, false croup is ameliorated, as a rule, on the 
second night, and largely disappears upon the third. The 
steady progress of the symptoms from the first should 
incline us to apprehend that we are dealing with a case of true 
croup. 

'' In false croup, the suffocative attacks do not occur so often, 
and are not so severe. Parents, and even physicians, often say 
that they have had children affected with several attacks of true 
croup ; undoubtedly, such cases are those of severe infantile 
laryngitis without any exudation whatever. 

" It may be mistaken for edema of the glottis, but if we note 
carefully the history of the case, and make a thorough exami- 
nation, we can usually settle the diagnosis. Palpation, which 
can always be employed before the case has progressed far, 
will put us on the right track. Spasm of the glottis is more 
likely to be confounded with this affection, but its convulsive 
nature enables us to distinguish it. Between the paroxysms the 
child is perfectly well ; there are no croupy sounds, no hoarse- 
ness, no stridor. In most instances, there is not in croup, or 
at least only very occasionally, a tendency to spasm of a carpo- 
pedal form. 

" Foreign bodies in the larynx induce symptoms which greatly 
resemble croup. The child is taken with sudden stridor and 
dyspnea, together with hoarseness and a sense of obstruction to 
respiration. In these cases, also, the history usually enables us 
to make a diagnosis. We have already given the points of di- 
agnosis between laryngeal diphtheritis and true croup. 

" Injuries of the larynx and morbid growths of the larynx 
give rise to croupy symptoms, but the diagnosis of these affec- 
tions is generally rendered easy by examination. 

" Prognosis. — True croup is an exceedingly fatal disease. The 
fatality ranges from 23 to 75 per cent. There are some cases 
which seem to resist, from the start, all treatment, however 
carefully and judiciously applied. With the evidence which 
we have of its deadliness, the statement of Cohen, since he has 
used the treatment of inhalations of steam in a hot room, should 
be carefully noted. 

" We cannot believe that healthy, robust children succumb as 
readily to the disease as do the feeble. Our view is emphatic- 
ally that it is a disease of scrofulous children ; that the strong 
and robust bear the brunt of it much more readily, and att'ord 
more hope of relief from treatment. A careful analysis of 
cases treated will show that the children attacked, who were, 
before, subject to enlarged glands and other manifestations of 
scrofulosis, succumb almost surely." 



548 THE DISEASES OF CHILDREN. 

(It is very rare to see a fatal case of croup among children 
who have been accustomed to plenty of outdoor exercise and 
who are free from scrofulous and syphilitic taint. The children 
of robust constitution, even though subject to privation and 
neglect, are not the favorite victims. It prefers the weaklings, 
the hot-house plants, that are given every care and surrounded 
with every luxury ; overfed, overclothed and kept indoors 
much of the time for fear of " taking cold." It is always the 
delicate, sensitive, pale-faced child who knows nothing about 
"roughing it," that falls an easy victim to croup.) 

'' The tendency to a fatal termination is increased by the oc- 
currence of complication. If we have bronchitis or pneumonia 
supervening, the danger is greatly intensified. Even when the 
membrane is confined largely to the larynx, there is but a 
slight prospect of recovery, though, of course, it is better than 
if the membrane extends above or below. There is little hope 
when we find severe and continued dyspnea with suffocative 
attacks occurring often, febrile movement high, and the stenosis 
marked, and stupor present, in a greater or less degree, with an 
intermittent pulse. 

" During the stage of asphyxia, it is generally the course for 
three paroxysms of collapse to occur. This clinical feature 
gives us an indication for tracheotomy, which should be 
promptly employed after the first attack of collapse. The pa- 
tient will rally from this under the use of a small amount of 
stimulant, and then the operation can be performed. 

" Exudation. — If there is any exudation on the pharynx, 
which my experience demonstrates to be somewhat rare, the 
true nature of the disease is certain ; but the exudation is usu- 
ally out of sight, and tends to extend downwards, and to in- 
volve the trachea and bronchi, even to the bronchioles, and all 
know the difficulty of laryngoscopic inspection in children. 
With a little tact, the use of the mirror in the throat with a 
a strong direct light may be effected in some instances ; such an 
examination will readily show the exudation. If not seen, its 
presence may be assumed from the history and symptoms, and, 
later, we have the expulsion of the membrane in flakes or casts. 
The larynx, trachea, and bronchioles have all been implicated, 
as post-mortem examinations have shown. Sometimes only 
inspissated mucus is thrown off for awhile. If inspiration and 
expiration are equally affected, we may assume the presence of 
adventitious membrane ; if, however, inspiration is difficult and 
expiration easy, we have merely a paralytic state of the glottis." 

Treatment. — The value of moist air in cases of croup is rec- 
ognized by all schools of practice. This can best be secured 
by using a steam atomizer, or a kettle of water kept boiling by 



ACUTE MEMBRANOUS LARTNGITIS. 549 

means of a spirit lamp, and limit the breathing-space of the 
patient by means of an improvised tent, erected over the whole, 
or upper portion of the bed. The vapor may be medicated 
with comp. tr. of benzoin, or carbolic acid, or still better, per- 
haps, with acetic acid. 

Dr. S. J. Bunstead, in the North American Practitioner 
speaks very highly of vinegar, as a therapeutic resource, both 
in catarrhal and membranous croup. He uses it in the form of 
vapor, pouring the liquid into a bread-pan, and then putting 
into it bricks or flatirons heated in the stove. When introduced 
under the tent, the air soon becomes saturated with acetic va- 
por. The inhalation of the vapor from slacking lime, has, it is 
claimed, saved the lives of many patients. 

The late Dr. Nicho. Francis Cooke never wearied of telling of 
a case of croup which occurred at one of the principal hotels in 
this city, and in the course of which thirty barrels of lime were 
used in this way, with successful results. Dr. Solis Cohen, of 
Philadelphia, claims to have saved every case of membranous 
laryngitis since he adopted the method of inhalations of steam 
in a heated room. His plan is to place the patient, after it is 
manifest there is an exudation, in a closed room heated to a 
temperature of 8o° Fahr., which should be constantly main- 
tained without intermission until the child is out of danger. 
The room is then surcharged with moisture by hanging pieces 
of cloth, or towels, wet with hot water, about the room. The 
water is placed upon the stove or grate, and by the placing of 
hot flatirons in pans of water, sufihcient steam is generated to 
produce a considerable degree of moisture. It is claimed that 
by this process the exudate is softened and finally exfoliated. 

During last summer, being called out of town for a few days, 
I was compelled to leave a child suffering from membranous 
croup with my friend, Dr. L. C. Grosvenor. The child had 
been ill for several days, and on the day I left the city was 
voiceless, and at times cyanotic. The respirations were very 
labored, and it seemed as if intubation would soon become 
necessary to prevent suffocation. On my return I found, 
somewhat to my surprise, that the child was making a good 
recovery, and no operative procedure had been necessary. I 
was informed by Prof. G. that on his first visit to the case 
he had instructed the parents to spray the child's throat with 
peroxide of hydrogen^ which produced its characteristic effects 
when pus is present, and after a few hours, a complete cast of 
the larynx with tracheal branches was coughed up, with an im- 
mediate relief of all serious symptoms. 

In this case there was at no time any visible exudation in the 
pharynx, or on the tonsils. The sick child was two-and-a-half 



550 THE DISEASES OF CHILDREN. 

years old, and the family consisted, besides the parents, of two 
other children, one younger, and one older than the sick one, 
who were necessarily constantly in the sick room, as the family 
occupied a flat of but three rooms. Notwithstanding these 
other children lived in the same rooms, breathed the same air, 
and were constantly about the patient, they remained well. 
This fact was to my mind conclusive proof that there was noth- 
ing diphtheritic about the attack. It was a case of simple, 
non-specific membranous laryngitis. I can only explain the 
action of the peroxide on the supposition that there must have 
been a secretion of pus behind and beneath the membrane 
which was decomposed by the inhalation, with the effect of 
loosening and throwing off of the deposit in the manner 
described. 

Dr. A. G. Beebe, of this city, whose conservatism of state- 
ment is well known, says that for twenty years past he has 
used with uninterrupted success, in the treatment of all forms of 
non-diphtheritic croup, a preparation of iodide of lime, as pre- 
pared by Billings, Clapp & Co., of Boston. It is a nearly black 
powder, and is given in doses of one-fourth to one-half grain of 
the crude drug at intervals of an hour, or if the symptoms are 
urgent, as often as every fifteen or thirty minutes for the first 
few doses. It should be continued until the dry, croupy cough 
gives place to a moist or catarrhal one, and until all danger of 
recurrence during the night has passed. It may be conveniently 
given mixed (not triturated) with sugar of milk, so as to make 
a convenient-sized dose, or it may be put into water ; but as it 
is a very unstable preparation, it should be exposed to light 
and air as little as practicable. 

The remedies which are especially homeopathic to mem- 
branous croup, are : 

Aconite. — Useful especially in the early stages, where it may 
limit the extent and intensity of the inflammation, and thus 
abort the formation of membrane or lessen its amount. 

Arsenicum. — Edema of the glottis, in pale and debilitated 
children ; great restlessness ; scanty urine ; great dypsnea. 

Bromin. — Cough dry and wheezy ; dyspnea marked ; expec- 
toration scanty; aggravation in spite of aconite ; hoarseness tend- 
ing to aphonia. 

Hepar Sulph. — Feeling as if there were a foreign body in the 
larynx ; stitching pains from ear to ear ; febrile movement 
marked ; inspiration difficult, expiration easy ; loose cough, but 
no expectoration ; rattling of moist mucus ; aggravation after 
midnight or towards morning. 

Kali Bichromicum. — Gradual and insidious onset ; at first 
only slight difficulty of breathing, which increases as the dis- 



ACUTE MEMBRANOUS LARYNGITIS. 551 

ease progresses ; hoarse voice, with constant paroxysmal cough ; 
tonsils and pharynx red and swollen ; tough, stringy mucus in 
mouth ; breath offensive ; especially adapted to diphtheritic 
cases, in which it covers better than any other remedy the to- 
tality of the symptoms. This remedy offers more hope than 
any other of softening the membrane and effecting its expul- 
sion. The more the case resembles one of non-malignant diph- 
theria, the more clearly is it indicated, and is well adapted to 
those cases where the diphtheria has extended into the larynx 
and trachea. 

Sanguinaria. — Sensation of swelling in the larynx, with ex- 
pectoration of thick mucus ; aphonia ; tormenting, exhaustive 
cough ; severe cough, without expectoration ; dryness of throat, 
with feeling of fullness of larynx, as if swollen. 

See also belladonna^ causticum^ lactic acid, lycopodiunt and 
spongia. 



CHAPTER VII. 

PNEUMONITIS (inflammation OF THE LUNGS). 

Synonyms. — First, Croupous Pneumonia ; Lung Fever ; Lobar 
Pneumonia. Second, Lobular Pneumonia ; Catarrhal Pneumo- 
nia ; Broncho-Pneumonia. 

It is rather to satisfy the demands of modern pathology than 
to subserve any material end, that the practice is here followed 
of dividing the pneumonias into lobar or croupous, and lob- 
ular or catarrhal pneumonia. While post-mortem examination 
of the lungs may reveal a marked distinction between the two 
varieties, the clinical differences observed during life are so 
vague and indefinite as to result rather in confusion than prac- 
tical help. While acute lobar pneumonia is probably quite 
common in childhood, it does not usually run the typical 
course which it does when adults are affected. It partakes 
more often of the symptoms of the catarrhal form, whether an en- 
tire lobe is involved or only certain portions or lobules, and the 
diagnostician must be very expert who can say positively in a 
given case which he has to deal with. Goodhart, in his American 
edition of '* Diseases of Children," edited by Starr, says : "Acute 
pneumonia, be it clinical, lobar, or lobular, seems to me to pre- 
sent such appearances in every case as make any distinction 
between the two forms, save one of degree, a very difficult 
matter." Nor are we aided in a practical way by the dictum of 
modern pathology, that lobar pneumonia is always " a specific, 
infectious, self-limited disease, giving rise to definite temporary 
pulmonary lesions ;" "^and broncho-pneumonia is an *' acute in- 
flammation of the bronchial lining membrane, which, by direct 
extension and mechanical phenomena incidental to the disease, 
involves the connective tissue, bronchioles and air cells."t It 
is quite probable that filthy and illy-ventilated homes, crowded 
tenements and damp basements may give rise to lobar pneu- 
monia, and to that extent and in that sense, it is undoubtedly 
*' infectious," but the same surroundings precisely may give 
rise, also, under certain other favoring conditions, to bronchitis^ 
asthma, laryngitis, or to lobular pneumonia. 



* Francis Minot, in Keating''s Cyclopedia. 
fF. Gordon Morrill, idem. 

(552) 



PXECMONITIS. 553 

The diagnosis between bronchitis and pneumonia in the adult 
is oftentimes exceedingl}' difficult, and with children impossible. 
The one is so intimately associated wnth the other that it re- 
quires a keen perception to discover where one leaves off and 
the other begins. There are those of the highest standing in 
the profession, and who are credited with having a verj^ extended 
experience in pulmonary diseases, who fail to make any distinc- 
tion between capillary bronchitis and certain forms of broncho- 
pneumonia. The distinction, when made, is of no practical 
value, either from a diagnostic, prognostic or therapeutic point 
of view. 

The vital function of the lungs is to aerate and depurate the 
blood, and any impairment of this function is attended with 
consequences which are disastrous in direct proportion to the 
amount of impairment. If a bronchiole is plugged up so as to 
exclude the air from the pulmonary vesicle to which it leads, 
it makes no practical difference whether the plug is of mucus 
or fibrin ; and the same is true of the vesicle itself. In either 
case the function of the part involved, be it bronchial or vesical, 
is impaired, and the act of respiration is to this extent curtailed. 

The etiology of the two varieties of pneumonia will only 
show "a distinction without a difference." While lobar and 
lobular pneumonia exhibit but trifling differences in their caus- 
ation and symptoms, their morbid anatomy does show marked 
peculiarities, which seem to distinguish them one from the 
other, as we shall proceed to explain. In croupous pneumonia, 
the pathological anatomy does not differ materially from that 
of the adult. 

There is, first, hyperemia or congestion ; next, solidification or 
hepatization, and then softening or liquefaction. 

Suppuration and gangrene of the lung, which are often seen 
in the adult, are very rare in the pneumonias of infancy. The 
three principal stages are, as a rule, not clearly defined, and it 
is no unusual thing to find them all existing at the same time 
in the affected organ. 

The first stage, or that of engorgement, is characterized by a 
darker color of the lung substance than is natural, and to the 
touch it conveys a doughy feeling, as if the lung was edema- 
tous. When cut, the lung tissue emits a frothy, bloody serum ; 
the frothy appearance being due to the admixture of air bub- 
bles with the lighter or darker sanguinolent fluid. A portion 
of lung in this stage, if thrown into w^ater, has sufficient air in 
it to keep it from sinking, and if lightly squeezed and washed, 
it can be restored to nearly its normal condition. The less air 
and more fluid found in the lung, the greater or more intense 
has been the inflammation. When the stage of hepatization is 



554 THE DISEASES OF CHILDREN. 

reached, the tissues are of a brick-red color; there is a greater 
degree of solidity, and the affected portions of the lung are fria- 
ble, resembling the liver, from which resemblance this stage 
derives its name. The hepatized lung is swollen, and often 
bears the imprint of the ribs on its surface. Slight pressure 
causes a very little bloody fluid to exude from the cut surface 
without a trace of air bubbles. 

A section of the lung has a streaked or speckled appearance, 
which is due to the bronchi and their vessels, which have es- 
caped the inflammation, and are, therefore, lighter colored. 
There are multitudes of minute elevations projecting from the 
cut surface, which are the alveoli distended with a viscid exu- 
dation. Under the microscope, this exudation is seen to be 
composed of a granular form of albuminoid matter, with red or 
white blood corpuscles, and an abundance of new cell-formations 
in the air vesicles. Sometimes fatty globules are seen, which 
are probably due to the fatty metamorphosis, which takes place 
prior to absorption of those products. 

A hepatized lung will often be found to have increased to ten 
times its normal weight. 

The morbid appearances of the third stage, or, as it some- 
times is called, the stage oi gray hepatizatiofiy are purely hypo- 
thetical. It is the stage of resolution ; of absorption. Doubt- 
less it retains many of the characteristics of the preceding stage. 
The color changes from dusky-red to granite-gray. It is still 
solid, granular and lacking air, and still sinks if thrown into 
water. But gradually the engorgement and infiltration 
undergo liquefaction and absorption. The fatty metamor- 
phosis before alluded to doubtless assists in this process of 
resolution. Children do not expectorate, and during conva- 
lescence from pneumonia are generally troubled but little from 
mucus in the tubes. Under unfavorable conditions, hepatiza- 
tion may undergo a change into purulent infiltration, in which 
case recovery is possible, but often long delayed. When lim- 
ited in extent, it may become surrounded by a wall of connect- 
ive tissue, and gradually be eliminated by abscess formation. 
The pleura corresponding to the pulmonary lesion is generally 
more or less involved, and in severe cases, there is the usual 
accompaniment of exudation of plastic lymph or serurn. 

The morbid appearances of lobular or broncho-pneumonia 
differ somewhat from those just described, especially when oc- 
curring in children. There is, perhaps, a greater dissemination 
of the morbid changes. The bronchial mucous membrane is 
more involved, and pours forth an abundant secretion, which 
naturally finds its way to the most dependent portion of the lung, 
which in a sick child is posteriorly ; and it is usually the 



PNEUMONITIS. 555 

posterior portion of the lungs that is affected in broncho- 
pneumonia. The inflammatory process not being restricted, as 
in lobar pneumonia, spreads irregularly in various directions. It 
invades the bronchioles and air-cells, and spreads also out- 
wardly to the bronchial walls, and the surrounding connective 
tissue. This extension of the inflammatory process and its re- 
sults may be rapid, and equivalent to a simultaneous invasion 
of all the tissues involved ; or it may be slow and gradual, oc- 
cupying weeks or even months. The manner in which the in- 
flammation may spread in broncho-pneumonia is either by the 
migration of the bronchial secretion, which acts as an irritant 
wherever it penetrates, or by the action of the original causes 
of the inflammation affecting different centers or foci, from 
which large portions of lung are involved by natural extension 
along the mucous surface. 

In all cases of average duration and severity, there is danger 
of collapse of some of the air-cells, which in some instances is 
a formidable accident. In these cases the walls of the alveoli, 
not being distended with air, come into apposition and remain 
so, until in the course of the process of resolution the bronchi- 
oles are free and open to the ingress of the inspired air, when, 
under favoring circumstances, they resume again their normal 
size and function. 

From this it will be seen that lobar pneumonia is, patholog- 
ically, a primary affection, affecting the parenchyma of the lung, 
and showing but little tendency to involve the bronchioles or 
the air vesicles ; while lobular or broncho-pneumonia is, as a rule, 
a secondary affection, involving the bronchioles and the alveoli 
by an extension of inflammation along their mucous lining. 
Lobar pneumonia produces solidification of pulmonary tissue 
by blood stasis ; lobular pneumonia, by incarcerated mucus, 
epithelium, pus or other products of inflammation originating 
in the tubes or their termini. Lobar pneumonia may be asso- 
ciated with bronchitis ; lobular pneumonia is always so asso- 
ciated. The former always involves a whole lobe or lobes, or 
a goodly part thereof, while the latter may involve but small 
and scattered portions of a lobe or lobes ; the one runs a brief 
and limited course, while the other, by migration of morbid 
secretions, or natural extension of inflammation, may perpetu- 
ate itself indefinitely. 

When lobar pneumonia becomes chronic, it is because of a 
failure, either in part or in whole, of nature's efforts to dispose 
of the products of inflammation ; but lobular pneumonia par- 
takes of the characteristics of all catarrhal affections, and be- 
comes chronic from the lowered tone of the tissue involved, 
and the inability of the patient to expel the catarrhal products. 



556 THE DISEASES OF CHILDREN. 

From a clinical point of view, it is plain to be seen how im- 
possible it is to distinguish in the majority of cases between an 
inflammation which is confined to the bronchioles or their ter- 
minal alveoli, and an inflammation just outside of these tissues. 
And it is just here where the intelligent homeopathic physician 
need suffer no confusion. To him the '' totality of tJie symptoms 
constitutes the disease,'' and the remedy or drug which best 
covers this " totality of symptoms," is the one sought for and 
prescribed with serene confidence in its curative action. 

Clinical History. — As a rule, pneumonia in children is not 
attended with prodromal symptoms. The chill which marks 
the onset of the disease in adults is generally lacking. If pres- 
ent at all, it is an ill-defined chilliness rather than a rigor, and 
of short duration. The early symptoms consist of cough, pain 
in the side, drowsiness, loss of appetite, and perhaps vomiting. 
Fever quickly follows, with flushed face, hot skin, restlessness, 
rapid pulse and accelerated breathing. In very young infants, 
convulsions are not uncommon. The temperature rapidly 
attains a height of 103°, or even 105°, and falls somewhat, 
ordinarily, as the second stage of the disease is reached. 

The disease is now fully developed, and the physical signs 
show engorgement of certain portions of the lungs correspond- 
ing to the parts affected. The cough is more or less frequent, 
and if the pleura is much involved, is attended with pain. A 
deep flush is noticeable on one or both cheeks, and an herpetic 
eruption is often seen on the lips. 

The breathing is hurried and shallow, and the nostrils dilate 
with each inspiration. The temperature is lowest in the morn- 
ing, the thermometer registering 102° or 103° Fahr. It rises 
towards midday, and by evening may reach as high as 104°, or 
even 106°, in severe cases. 

In broncho-pneumonia the temperature is subject to sudden 
variations. Every extension of inflammation involving any 
considerable number of fresh alveoli, is attended by a rise of 
fever. From this cause, the temperature may, in some cases, 
be higher in the morning than it is in the evening, or at mid- 
night. When areas of considerable size collapse, the dyspnea 
increases, the temperature diminishes, and the cough may en- 
tirely cease. This is of bad omen. The countenance soon 
becomes livid, the pulse small and weak, and unless a radical 
change takes place for the better, death ensues in the course of 
twenty-four or thirty-six hours. 

When the second stage has lasted for a period of from three 
to six days, in case a favorable change takes place, the tempera- 
ture falls suddenly, the breathing becomes easier and a profuse 
sweat marks the crisis of the disease. This does not occur, 



PNEUMONITIS. 557 

however, until the process set up by the inflammation is com- 
plete. In connection with the sweat, the patient usually experi- 
ences an inordinate flow of urine, or a diarrhea. 

Vomiting is present to a greater or less extent in nearly one- 
half of all cases. When broncho-pneumonia complicates measles, 
it generally occurs during the eruptive stage of that disease, or 
at least begins before the rash has entirely faded. In such 
cases, it runs a brief course, and death or convalescence is 
reached within a week. 

The duration of the different stages may be generalized as 
follows: The stage of engorgement lasts usually but a few 
hours ; that of red hepatization takes twenty-four or forty-eight 
hours for the exudative process to complete itself, and two to 
four days for solidification to continue before absorption begins ; 
the stage of gray hepatization is very apt to be terminated 
within a few days by death. In mild cases, the first stage may 
not progress to the development of inflammatory products, but 
may simply end by resolution. More commonly it goes on to 
hepatization, and then, instead of ending in purulent infiltration, 
it gives way to the reparative process of resolution or absorp- 
tion. This stage of resolution lasts for from three to five days 
and may last for weeks. In cases in which disease does not 
progress favorably, the addition of threatening symptoms usu- 
ally takes place about the third or fourth day. The tempera- 
ture rises, the pulse becomes smaller and more frequent, and 
there is a marked increase in the difficulty of breathing. The 
patient cannot lie down, but must be propped up w^ith pillows, 
while the act of respiration is performed laboriously. When 
cases are prolonged beyond five or six days, it has long been 
noticed that there is a decided tendency to ameliorate on cer- 
tain other days. These critical days, as they are called, are 
commonly the seventh, eleventh, fourteenth and twentieth. 
There is great tendency in pneumonia to relapse, and relapses 
always find their subject more or less exhausted by the previ- 
ous attack and less able to withstand the renewed shock of the 
inflammation. 

Physical Signs and Symptoms. — The diagnosis of pneumonia 
in adults is greatly facilitated by our ability to examine the 
sputa, and by the light which is shed upon obscure cases by 
auscultation and percussion. In infancy and early childhood, 
we do not receive any aid from the sputum, for the reason that 
none of it is expectorated. What little is raised to the fauces 
is immediately swallowed, and passes into the stomach, there 
to produce disorders in the shape of gastric inflammation or 
more often diarrhea. In infancy the strength is not sufficient 
to dislodge and dispose of the products of pulmonary disease, 



558 THE DISEASES OF CHILDREN. 

and this is one of the reasons why pneumonia is so perilous at 
this period of life. Owing to the limited areas affected in many 
cases of lobar pneumonia, and its position in the center of a 
lobe with healthy tissue all around it, it is sometimes late in 
the progress of a case before auscultation and percussion yield 
any satisfactory results. The difficulty of employing these aids 
to diagnosis, which are so valuable in treating adults, is en- 
hanced by the willfulness or fright of the child, which refuses to 
be pacified long enough for anything like a careful and critical 
examination. In cases where auscultation can be made availa- 
ble, it points to more or less embarrassment in the atmospheric 
ingress and egress into the minute bronchial ramifications. 
This hindrance to respiration is at times the result of great 
engorgement and stasis of blood, and again it is due to large 
secretory accumulations, or to simple collapse of the air-cells. 
During the first stage, or stage of engorgement, it is not com- 
mon to hear the fine crepitant rale which accompanies this 
condition in the adult. A moist rale is heard more frequently. 
During the first twelve hours, auscultation will give ordinarily 
the hissing or sibilant ronchus, from dryness of the mucous 
membrane from the inflammation ; but this is soon replaced by 
a moist ronchus, caused by the excessive mucus secretion 
which is being poured into the tubes. Percussion is likely to 
yield better results than auscultation. A dull or flat sound is 
elicited over the affected areas, and pleuritic complication will 
be shown by wincing or other evidence of pain when certain 
portions of the chest are percussed, which will be confirmed 
by a careful comparison of the two sides. During the stage of 
hepatization, true bronchial respiration can be clearly heard, 
after which it is replaced by moist crepitation. For some days 
before bronchial respiration is heard, there is marked dullness 
on percussion, and this dullness can be detected for a consider- 
able time after other signs of hepatization have disappeared. 
Vocal resonance is usually well marked all through the disease, 
but vocal fremitus is an uncertain sign, whether present or 
absent. When present only on one side, it has diagnostic 
value. 

Much can be learned by the general attitude and behavior of 
a child sick with pneumonia. There is complete loss of appe- 
tite. The child will not eat. It is too busy trying to breathe 
in a satisfactory manner. It will drink water, but thirst is not 
usually urgent. There is great apathy and indifference, which 
proceeds from exhaustion. It will hold a toy in its hand per- 
haps for hours together, making no complaint and no requests. 
The attention can be diverted but momentarily from the task in 
hand, that of obtaining sufficient oxygen to sustain life. The 



PNEUMONITIS. 559 

face wears an anxious look, and the alae nasi work vigorously. 
There is retraction of the ribs and intercostal spaces, especially 
in the lower and lateral portions of the chest, and there is de- 
pression of the epigastrium. The deep flush on one or both 
cheeks is rarely absent, but when on one side only it does not 
necessarily correspond with that of the lung affected. Certain 
nervous symptoms are sometimes observed, but usually are not 
marked, nor are they characteristic of the disease. Mild delir- 
ium may be present, and in severe cases this may amount to 
acute mania. Persistent drowsiness or stupor are more com- 
mon. The pulse is very rapid, rarely under one hundred and 
twenty, and sometimes one hundred and forty or fifty in the 
minute. 

The breathing is also greatly increased in rapidity, there 
being sometimes as many as sixty, eighty or even one hundred 
respirations to the minute. The significance between the ratio 
of pulse to respiration we shall speak of in connection with 
bronchitis. The tongue is usually coated, but may be red and 
irritable about the edges. When the disease is prolonged, the 
mouth and tongue become dry, and sordes may collect on lips 
and teeth. Vomiting, as already stated, is not uncommon, but 
is not usually persistent. Diarrhea from intestinal catarrh is 
frequently met with and is sometimes very obstinate. 

Lobar pneumonia usually terminates by crisis ; lobular by 
lysis. 

Etiology. — It is said that healthy children are quite as liable 
to attacks of pneumonia as are those who are cachectic. This 
is highly improbable. A healthy, rugged child is more likely 
to resist any and all noxious influences than one who is not so. 
Pneumonia is no exception to this rule. 

The effect of bad or unsanitary influences, such as come from 
living in basements, unsewered localities, in houses newly plas- 
tered, and unhealthy surroundings generally, may be set down 
as among the predisposing causes. But, undoubtedly, expo- 
sure to cold, insufificient clothing, damp currents of air, together 
with dietetic irregularities, are mainly responsible as exciting 
causes. The disease is not contagious, although it may appear 
in epidemic form, from a large number of children being ex- 
posed at the same time to the same malign influence. Either 
one attack predisposes to others, or some children are much 
more susceptible to it than are others. It is no uncommon thing 
for a child to have repeated attacks. Various authorities are 
cited who have witnessed a repetition in the same individual 
of pneumonia as many as ten or more times, the first attack 
occurring in infancy. 

Diagnosis. — The differential diagnosis between pneumonia 



560 THE DISEASES OF CHILDREN. 

and bronchitis in the early stage of either disease is not easy. 
It may be said, however, that the early symptoms in the 
former are more intense as a rule than in the latter. The fever 
is higher and the dyspnea greater. 

Between croupous and broncho-pneumonia the symptomatic 
line is not very clearly drawn, except in typical cases. There 
is more apt to be vomiting, chills, headache, delirium, or con- 
vulsions in the former than in the latter. Broncho-pneumonia 
is the form most likely to follow eruptive fevers, especially 
measles. Indeed, a previous history of measles, whooping 
cough, scarlatina or bronchitis makes lobular pneumonia prob- 
able rather than croupous. 

A previous history of good health up to the time of seizure 
with pneumonia renders it probable that the attack is of the 
croupous variety. In the latter the ratio of pulse and respira- 
tion is steadier, that is to say, less subject to variations than 
the other. If the age of the child is under five years, the type 
of the pneumonia is more likely to be lobular than lobar, for it 
is during the period of dentition that broncho-pneumonia most 
frequently attacks children. After this period either form may 
occur. In lobar pneumonia the affection is usually confined to 
one lung, w4iile the opposite is true of broncho-pneumonia. In 
one hundred and ninety-one cases cited by F. Gordon Morrill, 
evidences of consolidation in both lungs, were obtained in only 
six and three-tenths per cent. In lobar pneumonia, the upper 
lobes are more commonly affected than in the lobular variety, the 
latter being more indiscriminate in its preferences. The average 
duration of the disease is different in the two varieties ; that of 
lobar being from a week to ten days, while in broncho-pneumo- 
nia it is indefinite, but much longer. 

To recapitulate : pneumonia occurring under three years of 
age is ordinarily catarrhal, and is preceded by and accompanied 
with more or less bronchitis. It is the form which is most apt 
to be associated with measles, scarlatina and whooping cough. 
Lobar or croupous pneumonia, on the other hand, is more apt 
to be a primary disease ; its beginning more abrupt, and its du- 
ration shorter. Whichever form of pneumonitis is present, the 
physical signs will show dullness on percussion, bronchophony 
and bronchial respiration of higher pitch and harsher than 
the normal vesicular murmur. In addition, there are always in 
typical cases the flushed cheek, the hurried breathing, quick 
pulse, indifference to food and pronounced apathy. 

Prognosis. — Pneumonia is one of the most fatal of infantile 
maladies. No matter which form of the disease may be 
present in a given case, the child's life is imperilled. The na- 
ture of the affection is such that it strikes at the very citadel of 



PNEUMONITIS. 561 

life. A child that cannot breathe cannot live ; and the only 
reason that cases do recover is because only a portion of the 
lung structure is involved, instead of the whole. In croupous 
pneumonia sometimes only small areas of lung are involved, and 
at most, in ordinary cases, but a single lobe. The affected area 
is limited, and the consequent damage restricted. There is 
still enough unaffected pulmonary mucous surface to carry on 
the vital functions of oxygenation and depuration until resolu- 
tion is accomplished. Hence the mortality in this form of 
pneumonia is but small, especially in healthy, robust subjects. 
Barthez publishes a table of two hundred and twelve cases of 
pneumonia occurring between the ages of two and fifteen years, 
with only two fatalities. But with catarrhal or broncho-pneu- 
monia, the case is different. As we have seen, it is most fre- 
quent during the period of dentition, when the system is already 
under a strain, and it often occurs as a complication in diseases, 
like measles or whooping cough, which have already lowered 
the general tone of the system and lessened the powers of re- 
sistance. Many deaths from pneumonia result directly from 
exhaustion. Adults in the vigor of their maturity are able to 
raise and expel the morbid products of pulmonary inflamma- 
tion before these products have had time to undergo putrefac- 
tive change ; but infants and young children have neither the 
knowledge nor the power to rid themselves of these mischievous 
secretions. Hence the mortality from broncho-pneumonia is 
large, and the younger the subjects, other things being equal, 
the greater the mortality. Just what the ratio of deaths to 
cases is, is uncertain. Some authorities place it as high as fifty 
per cent. This is probably much too high in cases treated hom- 
eopathically. I have a record of twenty-two cases, with but 
three deaths. The average age of these cases was two and 
three-quarter years. All of them occurred in private practice. 

Any exhaustive disease preceding or accompanying the pneu- 
monia increases its danger, and the younger the child and more 
feeble the constitution, the less likelihood there is of recovery. 
Unfavorable symptoms are increasing rapidity and feebleness 
of the pulse, pallor of countenance, inability of the patient to 
support the head, showing inordinate weakness ; refusal to no- 
tice or be amused with toys ; absence of tears when crying; 
and the appearance of pemphigus on the face or elsewhere. 

Symptoms on which a favorable prognosis may be based are 
moderate acceleration of pulse ; retained ability to support the 
head ; decided and permanent lowering of the temperature ; 
desire for food ; return of tears after they have been absent, 
etc. When the inflammation begins to abate, there is generally 
progressive improvement ; but the danger of relapse must not 
D. C— 36 



562 THE DISEASES OF CHILDREN. 

be forgotten, and supportive measures will be necessary to 
combat the tendency to asthenia. 

Treatment, — The latter part of the last sentence should have 
been printed in italics or small capitals, the more to impress 
the young practitioner with one of the great dangers to be en- 
countered in this disease. Before the benign help and influence 
of homeopathy came to the rescue of suffering humanity, blood- 
letting, mercurials, blisters, antimony, and other depressants 
carried off more victims than the inflammation itself. While 
the main dependence is to be placed on the indicated remedies, 
the tendency to exhaustion must not be lost sight of for a mo- 
ment. Such diffusible stimulants as brandy, whisky, ammonia, 
etc., may avert impending suffocation, and give time for the 
chosen remedy to act. 

We have seen such salutary results from the judicious use 
of hot fomentations of the chest with flannel wrung out of hot 
water and hot poultices of linseed meal, that we would not 
treat a case of capillary bronchitis or pneumonia without one 
or the other of them. Poultices are preferable, because they 
retain their heat longer, and do not wet the clothing. They 
should be covered, as soon as applied, with a layer of oil-silk, 
in order to retain the heat as long as possible, and they should 
be changed or re-applied as soon as cool. 

Internal Remedies. — These are not very numerous, but are 
wonderfully effective. We shall drop the alphabetical arrange- 
ment of drugs here and name them, for better perspicuity, in 
the order of their relative value. 

Tartar Emetic. — In well-established cases, especially of 
broncho-pneumonia, this remedy is paramount to all others. It 
comes the nearest to being a true similimum to all of the essen- 
tial features of the disease, viz., loose, mucus cough ; great 
oppression in breathing ; quick, hurried respiration ; crepitant 
rale ; mucus ronchus ; great anxiety of countenance ; vomit- 
ing ; anorexia. It should be given in the third decimal tritu- 
ration, two to three grains in a tumbler half filled with water, 
of which a teaspoonful may be given every hour, half-hour, 
or in urgent cases, every fifteen minutes, until symptoms 
ameliorate. 

Phosphorus. — Incessant, short, dry, hacking cough; scant 
secretion in the bronchi ; crepitant rale ; dryness of air pas- 
sages ; bronchial respiration ; collapse of lung ; short, laborious 
breathing ; rapid prostration ; sunken features ; dry lips and 
tongue; involuntary diarrhea; threatened paralysis of lungs; 
hepatization of the lower half of right lung. Pleuro-pneumonia, 
with extensive implication of the pleura. (Bry.) " Phosphorus 
is our great tonic to the heart and lungs." — Lilienthal. 



PNE UMONI TIS— REMEDIES. 563 

Aconite. — First stage, hot, dry skin ; arterial thrill ; sibilant 
ronchus; hasty respiration ; agitated manner; pulmonary hy- 
peremia ; percussion sound still clear and crepitating rales dis- 
tinctly audible. Aconite is of little use after stage of hepati- 
zation is fully inaugurated. 

Gelsemiiim. — High fever without thirst; intermittent parox- 
ysms of hoarseness, and voice becomes very weak ; sighing res- 
piration ; local pains on both sides under scapula ; especially 
valuable in pneumonia following eruption of measles ; pulse 
slow and full ; short paroxysms of pain in superior part of right 
lung, on taking a deep breath ; nausea, vomiting. 

Bryo7iia. — Great dyspnea, aggravated by the slightest motion ; 
pleuro-pneumonia ; short, jerky, incomplete respiration ; tho- 
racic tenderness ; tongue foul ; gastric catarrh ; thirst for large 
quantities of water ; abdominal breathing ; inclination to lie 
perfectly still. 

Cuprum. — Pneumonia complicating whooping cough ; begin- 
ning paralysis of lungs with sudden difficulty of breathing, 
which is followed by great prostration ; the face is earthy, dirty- 
bluish ; roof of mouth red. There may be diarrhea, connected 
with sour-smelling perspiration (Deschere), when formation of 
abscess threatens. 

Cannabis Sativa. — Constant delirium during the fever, with 
hard, teasing, sometimes incessant cough (phos.), and vomiting 
of bilious, greenish matter ; the pulse is weak, frequently al- 
most imperceptible ; violent palpitation of the heart on moving 
the body. Lobar pneumonia: lung lesion limited to one lobe 
or to one side. 

Opium. — Pulmonary inflammation disguised by symptoms of 
cerebral congestion and oppression ; cyanotic color of upper 
part of body, with slow, stertorous breathing ; anxious sleep 
with starts (bell.) ; hot perspiration all over the body, except 
lower limbs ; parts covered by a heavy crop of sudamina. The 
patient gropes with his hands around the bed as though he 
were hunting for something. — Hoyne, 

Sanguinaria. — This remedy, according to Hale, occupies a 
middle ground between tartar emetic and phosphorus. Dr. 
Hale says of it, in this connection : " It has many symptoms in 
common with both, and others possessed by neither. The gen- 
eral symptoms indicating sanguinaria are extreme dj^spnea, 
short, accelerated, constrained breathing ; the pulse is quick 
and small, the face and extremities are inclined to be cold, or 
the hands and feet burning hot, with circumscribed redness and 
burning heat of the cheeks, especially in the afternoon. The 
patient lies upon the back and is most comfortable with the 
head elevated ; the dry cough will awaken the patient out of 



564 THE DISEASES OF CHILDREN. 

sleep, and will not cease until he sits up in bed. There is fre- 
quent gaping after the cough." 

Belladomia, hyoscyamus, are the chief remedies for the de- 
lirium which so frequently complicates pneumonia, when it is 
due to arterial or venous congestion. They can be considered 
merely as intercurrent remedies, when the upper portion of the 
lung is involved and the delirium is directly referable to circu- 
latory disturbance, and not to blood change, and especially if 
the head symptoms are prominent from the start. Belladonna 
may be given at once, and with better effect than aconite. 
Hyoscyamus is especially valuable in hypostatic pneumonia, 
with delirium, not so violent in form as that of belladonna. 
There is less congestion, but more nervous excitement, with 
talkativeness and hallucinations, under hyoscyamus. 

Mercurius. — General flagging of vital energies ; dullness over 
lung on percussion ; absence of respiratory murmur and crepi- 
tant rales ; bronchial ronchus ; livid expression of countenance. 
All these symptoms indicate consolidation of the part involved. 
The cough in bell., hyos. and mercurius is in all three remedies 
aggravated at night. Besides the remedies here enumerated, 
attention is called to veratrum viride, digitalis, ipecac, kali 
bichromicum, kali carbonicum^ cina^ spongia, lycopodium^ etc. 



CHAPTER VIII. 

BRONCHITIS (bronchial CATARRH). 

Definition. — Bronchitis is an inflammation of the mucous 
lining of the bronchial tubes, attended with more or less exu- 
dation of mucus in excess of normal requirements. It may 
be either acute or chronic. When it affects the bronchioles, 
which are the ultimate divisions of the bronchial tree from 
which the air cells begin to be given off, it is called '' capillary 
bronchitis." This form of bronchitis will be treated of in a 
separate section. 

Etiology. — Whatever confusion and murkiness may have 
clouded the etiological atmosphere surrounding pneumonitis, 
are dispelled when we come to consider the causes producing 
an inflammation of the bronchial tubes. All mucous mem- 
branes everywhere are liable to congestion and inflammation 
from the effects of cold, dampness and dust, or anything, in 
fact, which may set up an irritation in their surfaces. We have 
cystitis from acrid kidney secretions ; diarrhea from the inhibi- 
tion of indigestible food, or from the effect of cold and damp- 
ness, checking the exhalations from the skin and forcing them 
to find an exit through the intestinal mucous membranes. The 
relations between the skin and the bronchial lining are still 
more close and intimate, and any shock to the skin is liable to be 
felt at once by the pulmonary mucous lining. A slight draught, 
a sudden, although slight change in the temperature, will often 
excite irritation in the schneiderian membrane, and cause sneez- 
ing, which may be the commencement of an acute coryza, an 
angina or a bronchitis. Steady, dry cold does not seem to act 
as a cause of pulmonary inflammation, as it is said to be a rare 
complaint in the arctic regions in winter. Along the sea-coast 
and in our lake regions, catarrhs of all kinds are endemic, but 
are of most frequent occurrence during the spring and autumn 
months, when the atmosphere is often saturated with moisture, 
and the temperature is subject to sudden and marked varia- 
tions. Superheated houses, by relaxing the skin and causing 
draughts, are hot-beds of catarrh. There is always more dan- 
ger from excessive than from deficient heating of homes. Im- 
pure air, from whatever source, or however produced, is an 

(565) 



566 THE DISEASES OF CHILDREN. 

irritant to the respiratory mucous membranes, and paves the 
way for bronchitis or pneumonia. 

The period of first dentition is one during which children are 
especially liable to catarrhs of all kinds. The respiratory tract 
affords no exception to the rule. 

A cold in the head, or a mild laryngitis, if neglected, is very 
liable to creep along down into the bronchi and develop there 
an inflammation of greater or less extent. Certain diseases, 
such as the eruptive fevers (notably measles), which alter the 
quality of the blood and reduce the general tone of the system, 
are very often accompanied or followed by bronchitis. Indeed, 
it may be said that more or less bronchitis is always associated 
with measles. Whooping cough is also usually accompanied 
with some catarrh of the bronchial mucous membrane. Doubt- 
less there are other causes of bronchial inflammation, of which 
we know little or nothing, such as electrical and telluric dis- 
turbances, barometric changes, and the like, which at times 
make such trouble epidemic. With so many etiological fac- 
tors as those well known and generally recognized, it is no 
wonder that bronchitis is one of the commonest affections of 
childhood. It is most commonly met with as a disease of the 
large and medium-sized tubes, and as such we shall consider it 
here. 

Symptoms. — In many, perhaps most, cases of bronchitis oc- 
curring in children under five, there is an accompanying or pre- 
ceding catarrh of nose and throat. Its onset may, however, be 
sudden and without warning or complication. There is high 
fever (102° or 103°), labored breathing, quick pulse and a fre- 
quent short, dry, hacking cough, which subsequently becomes 
moist and rattling. The tongue is thickly furred. In nursing 
babies the coryza obstructs the breathing power, and makes 
them constantly let go the nipple to take breath. It is said 
that a child that can scream long and loud cannot have 
pneumonia ; and it is equally true that an infant who can nurse 
without interruption on account of " catching the breath," 
cannot have bronchitis. 

Bronchitis of mild type, that in which only the larger bron- 
chial tubes are affected, is common to all periods of infancy and 
childhood. In the beginning, the respiration and pulse are 
scarcely accelerated, and the appetite is but little impaired. 
Auscultation in these mild cases reveals coarse mucus rales in 
the larger bronchial tubes, while the smaller ones are free from 
mucus. Sibilant and sonorous rales are also observed, especially 
in the commencement of the disease, when the secretion of 
mucus is suppressed or scanty. By the second or third day, 
and usually sooner under appropriate treatment, the cough 



BRONCHITIS. 567 

becomes looser and the sputa, if obtainable, will be found to 
consist of frothy mucus, with an admixture of pus and epithelial 
cells. As the disease continues, the pus becomes more abund- 
ant. The duration of these symptoms may be from two or 
three days to a week or more. In rare instances the bronchitis 
fails to yield to treatment, and takes on a chronic form which 
may last indefinitely. The disease may be either primary — that 
is, unassociated with any other disease — or it may be secondary 
to coryza, laryngitis, pharyngitis ; to measles, whooping cough, 
or any of the continued or remittent fevers. 

Prognosis. — When bronchitis is confined to the larger or 
medium-sized tubes, is uncomplicated, and occurs in a previously 
healthy child, having good surroundings and good care, the 
prognosis is always favorable. In other cases, with poor sur- 
roundings and poor care, and occurring in a child already 
enfeebled by acute or chronic disorders, the prognosis should 
be guarded. It should not be forgotten that there is always 
danger of a mild and simple bronchitis extending into the 
bronchioles and the alveoli, and producing or becoming that 
much more serious malady, capillary bronchitis, or, as some 
authors prefer to call it, broncho-pneumonia. 

Diag7iosis. — The diagnosis of bronchitis is usually unattended 
with difficulty. The respiration is not hurried and labored, as 
it is in pneumonia. Auscultation discovers coarse mucus 
rales, if the larger tubes are involved, and fine, subcrepitant 
rales, if the smaller tubes are affected. Percussion gives clear 
resonance on both sides, except in those cases in which collapse 
of lung or pneumonia has superseded. The absence of hoarse- 
ness, stridulous inspiration, and croupy cough distinguishes it 
from laryngitis ; and the stitch-like pain which belongs to 
pleurisy is wanting. 

Treatment. — To go over the list of remedies suitable for 
bronchitis, would be to reiterate what has already been said in 
the previous section and in the remarks introducing the subject 
of respiratory diseases. The reader is referred particularly to 
pages 512, 514, where the repertory of cough remedies is very 
full and complete. There are no special remedies for bronchitis 
that have not been already mentioned and their special indica- 
tions pointed out. Whatever omission there may be, if any, 
in these previous sections, will be supplied in the following 
section on Capillary Bronchitis. 

In saying this, it must not be inferred that the simple form 
of bronchitis here considered, is unworthy of serious and care- 
ful treatment. On the contrary, a mild and apparently inno- 
cent inflammatory catarrh of the large and medium-sized tubes 
may, if neglected, extend to the bronchioles and the air cells, 



568 THE DISEASES OF CHILDREN. 

and speedily result in a broncho-pneumonia of serious aspect, 
or take on a chronic form, with its possibilities of eventuating 
in phthisis pulmonalis, asthma, emphysema, or collapse of the 
lungs (atelectasis). 

CAPILLARY BRONCHITIS. 

This term is used to indicate a form of bronchitis affecting 
principally the finer or finest ramifications of the bronchial tree, 
just before the air vesicles, or alveoli, are given off. 

The term is objected to by some hypercritical authorities, 
who have suggested, as more indicative of its morbid anatomy, 
the term "bronchiolitis;" others have endeavored to substi- 
tute the term *' terminal bronchitis" as more expressive and 
correct. To our own mind, neither of these expressions is less 
open to criticism than that of capillary bronchitis. In many 
cases where the bronchioles are manifestly affected, the inflam- 
matory process stops short of the termini, in which cases '* ter- 
minal " bronchitis would not apply. *' Bronchiolitis " is perhaps 
less objectionable, but we can see no particular advantage in 
substituting a new term for an old and time-honored one, when 
the one is just as definite and comprehensive as the other. 

Retaining then, the old term, capillary bronchitis, out of 
respect for its age, if nothing more, let us see what the term 
implies. 

We have already seen pointed out that in the ordinary and 
simple form of bronchitis, affecting the large or medium-sized 
tubes, we have an inflammation of the mucous lining of these 
tubes, eventuating in a catarrhal effusion upon the tubular sur- 
faces, attended by cough and expectoration. There is no ob- 
struction to respiration, or next to none, because the caliber of 
the affected tubes is not completely filled by the effused mucus. 
In other words, there is no stenosis or occlusion. When, how- 
ever, the minute bronchioles are invaded, the case is very dif- 
ferent. On account of the narrowness of the tube, the inflam- 
matory swelling of the lining membrane of the bronchioles is 
sufficient alone to produce suffocative attacks (bronchitis 
sicca). In these finer air tubes, mucus or pus has precisely the 
same effect as dense fibrinous material has in the larger tubes. 
Air cannot penetrate beyond the obstruction and enter the air 
vesicles, which are almost certain to collapse in consequence. 
In case the air cells do not collapse, the contiguous inflamma- 
tion is tolerably sure to invade them, with consequent exuda- 
tion and infiltration. The inspired air cannot reach the blood, 
and decarbonization of this fluid is as effectually arrested as if 
the larynx or trachea were plugged with a pseudo-membrane.. 



CAPILLARY BRONCHITIS. 569 

The danger from capillary bronchitis is in direct proportion to 
the number of bronchioles affected. From a pathological 
standpoint, capillary bronchitis and simple bronchitis are pre- 
cisely the same thing ; the latter affecting the larger or medium 
tubes, the former affecting the smaller and finer. There is no 
difference at all in the process, except one of grade. Capillary 
bronchitis is essentially a disease of infancy. It may be pri- 
mary, the bronchioles being involved from the start ; or it may 
arise from extension of the inflammation, which has primarily 
affected the larger tubes. 

Symptoms and Course. — In capillary bronchitis the symptoms 
are much more intense than in the ordinary form of the disease. 
The dypsnea is greater, the fever is higher, and there is a 
greater degree of restlessness and anxiety. The difficulty of 
breathing, in these cases, arises from two sources : one, the 
swelling of the membrane lining the bronchioles ; the other, 
the secretion. The latter may be small in amount, in which 
case the dypsnea will be but moderate ; but when there exists 
an extensive implication of the bronchi, it increases to a severe 
degree, and suffocative attacks with cyanosis ensue ; the victims 
are unable to breathe unless they are raised ; the nostrils dilate, 
and the alae nasi work spasmodically, as they do in broncho- 
pneumonia. The cough is violent and distressing, but not so 
painful as in pleurisy or pleuro-pneumonia. It may occur in 
paroxysms, or be more or less continuous. The rapidity of respi- 
ration is greatly increased, sometimes reaching as many as sixty, 
eighty, or even more per minute. In this connection Dr. Mar- 
tin Deschere makes the point that, " In young subjects espe- 
cially, forty to fifty respirations per minute may be observed 
without necessarily denoting great danger. But if a rise to 
sixty or eighty and more respirations takes place, it is a sure 
sign that the finer tubes have become involved." 

The quicker the respiratory movements, the shorter and more 
superficial will they be. At the same time, inspiration becomes 
more labored, all the auxiHary muscles are brought into play, 
and the presence of a moan with each expiration is pathog- 
nomonic of grave respiratory affection. Percussion even now 
will be normal, but auscultation will give rattling noises of all 
kinds and qualities, as the large tubes participate. 

The relation of respiration to pulse is of great importance. 
It may change from the normal ratio of one respiration to three 
or four beats of the heart, to one respiration to two beats or 
less, according to the severity of the attack. As long as this 
relation does not exceed one to two (with a pulse of 140-150 
in children under two years), we need not be alarmed ; but 
if it becomes closer than one to two, there will be danger of 



570 THE DISEASES OF CHILDREN. 

collapse ; and if respiration reaches lOO, with a pulse of two 
hundred or more, paralysis of the heart may set in from over- 
strain, though here the ratio is but one to two. 

Henoch is accredited with a diagnostic point which is worth 
remembering. He says, ** Children who are able to nurse un- 
interruptedly, without stopping to take breath, have either 
acute coryza or capillary bronchitis." He values this symptom 
of uninterrupted nursing so highly, that he advises always hav- 
ing the child put to the breast in the presence of the physician 
while making his examination, to enable him to judge of its 
manner of nursing. 

Deschere advises that "Children from one to three years of age 
should be examined while in an upright position (sitting on the 
mother's or nurse's lap). Here a little kindness and tact will 
generally succeed, except in ' crude-antimony ' children, who 
do not want to be touched. But this very peculiarity is an 
excellent indication for the drug, under the influence of which 
our patient is safe until the next visit, when he will be found 
of a more amiable disposition." 

**The cough, although a most prominent symptom, is not a 
reliable guide to the severity of the affection. There may be 
extensive inflammation of the bronchi or the bronchioles, as 
evidenced by the pulse, temperature, respiration and physical 
signs, and yet the cough be suppressed. Again, during conva- 
lescence, there may be a continuous and most harassing cough, 
exhausting to the child, while at the same time, all the other 
symptoms may be most favorable. The temperature in capil- 
lary bronchitis will not rise above 103° Fahr., unless the air 
cells are themselves involved, constituting the disease one of 
broncho-pneumonia; but we cannot positively deny, in a given 
case, the presence of pneumonia, although the temperature 
may be below 104°. All observers agree on the unsatisfactory 
results of percussion in this form of pneumonia, and if we con- 
sider the gradual and dispersed manner in which the inflamma- 
tion spreads into the air cells, affecting only small points at 
one time, these results are easily understood " (Deschere in 
HaJineviannian Monthly, ^^"^X., 1882). Among the other and gen- 
eral symptoms which are to be noticed in this connection, is 
epigastric pain. It is not of great significance, for sick children 
are proverbial for having aches and pains, which they rarely 
locate at the seat of disease, or even that of real distress. Ow- 
ing to the age of the child when capillary bronchitis is most 
common, it is not always possible to obtain the sputa. It is in 
most instances swallowed into the stomach, where it undergoes 
change before it is vomited up. It is sometimes possible, how- 
ever, during a fit of coughing, to throw the child forward, and 



CAPILLART BRONCHITIS. 571 

thus secure enough for examination upon a cloth. At first the 
secretion is tough and tenacious ; afterwards it becomes muco- 
purulent and thinner. It is usually yellowish-white in appear- 
ance, and often looks like foam, mixed with thin threads, from 
the minute bronchioles of which they are casts. 

The temperature in this affection, as has been already ob- 
served, is higher than in the ordinary form of bronchitis, but 
not so high as in pneumonia. By careful observation it is often 
possible to note the transition from most extensive capillary 
bronchitis to broncho-pneumonia. The increased temperature 
which accompanies such a transition is very obvious. A com- 
paratively circumscribed pneumonitis will give rise to a rapid 
elevation of temperature much more quickly than even a diffuse 
bronchial catarrh, even though implicating the finer tubes. 
Gastric disturbances are common. There is complete loss of 
appetite, coated tongue, and sometimes vomiting of mucus. 
The bowels are apt to be constipated at first, while later diar- 
rhea, excited by the sw^allowing of so much mucus, is the rule. 
In the severer grades, defective aeration of the blood is ob- 
served, the respiratory process is insufficient, and gradual 
suffocation ensues. The blood is charged with carbonic-acid 
gas, and its oxygen is correspondingly deficient ; the cyanosis 
deepens, the face is turbid, bloated, dusky, or livid. The lips, 
tip of the nose, malar protuberances, tongue and ears are very 
livid, and in marked contrast with the pallor of the surrounding 
skin. The veins of the head and neck swell. The fingers and 
toes, especially the nails, show also the cyanosis ; the feet and 
hands may become edematous. The temperature falls, clammy 
sweats break out, particularly about the face, and then involve 
the whole body. The patient is exhausted, the head drops 
about in any direction. The pulse is very rapid, weak, small, 
compressible, and often irregular. The patient is restless ; there 
is an anxious expression of countenance, which continues until 
the mind begins to wander, and the patient grows dull and 
apathetic, falling into a drowsy state ; then a stupor, and finally 
a complete coma ensues, which precedes death. In some chil- 
dren there may be convulsions. The cough is not severe, and 
no attempt is made at expectorating ; the breathing is very 
rapid, and gradually grows more shallow. Bronchial rales are 
plainly audible, and as the large tubes become filled, there is 
distinct crackling. Death occurs either from blocking up the 
large bronchi suddenly, or from extensive pulmonary collapse, 
congestion giving rise to edema, or from lobular or lobar pneu- 
monia. 

Diagnosis. — From what has already been said, the diagnosis 
of capillary bronchitis can only be obscured when it verges on 



572 THE DISEASES OF CHILDREN. 

that diaphanous or hypothetical Hne which divides it from 
broncho-pneumonia. The distinction is not important. 

The difference is merely one of degree. In capillary bron- 
chitis, the rales are usually more diffuse and of larger size, 
while in lobular pneumonia they are limited to the affected 
space, usually at the bases of the lungs, where they are irregu- 
larly scattered. In lobular pneumonia we have more frequent 
respirations and less dyspnea, and less tendency to cyanosis. 
The temperature in pneumonia is higher, and dullness on per- 
cussion is more marked. 

The duration of capillary bronchitis is usually four or five 
days, but may be longer. The fatal cases occur usually about 
the sixth to the eighth day. The symptoms which indicate a 
fatal termination are great lividity of countenance, cyanosis, 
coldness of extremities, dullness of comprehension, coma and 
convulsions. Favorable signs are lowering of temperature, 
greater ease in breathing, ability to nurse, desire for food, bet- 
ter color of countenance, increased strength. 

Prognosis. — Capillary bronchitis is always a grave disease, but 
under appropriate treatment, even those cases which seem to 
be the most desperate oftentimes recover. 

To the unwary the disease is full of surprises, and every case 
demands the closest attention of both physician and attendants. 
To the weakling, the affection is one full of hazard, and to the 
robust is not without danger. The prognosis should, therefore, 
be guarded but hopeful. 

Treatment. — An even and equable temperature should be 
maintained in the room of the patient — 70° or 72° Fahr. is 
about right. Moisture of air favors expectoration and dimin- 
ishes the cough. Inhalations of steam are, therefore, beneficial. 
A jacket of cotton-wool may be made to lightly envelope the 
chest, or still better, a jacket-poultice of linseed meal may be 
used, and kept warm and moist by an outer envelop of oil silk. 
If poultices are used, they should be renewed as soon as cool, 
for they are only of use when moist and warm. When taken off, 
they should be replaced with cotton-wool, or absorbent cotton. 

The main dependence in the conduct of a case of capillary 
bronchitis, however, must be in the homeopathic remedy, and 
the indications for certain drugs have been so admirably given 
in a paper read before the American Pedological Association 
by Dr. Deschere, some years ago, that we are impelled to make 
use of them here, for the benefit of our readers. 

In doing so we desire to express our obligations to the au- 
thor for the liberty taken : 

" The keynotes for the selection of the homeopathic remedy 
must be looked for in the character of the cough, the manner 



CAPILLARY BRONCHITIS. 573 

of breathing, its character and frequency, the mental condition 
and the sleep. 

" After that we must take into consideration the general ap- 
pearance, as to constitution, and grade of prostration, the ex- 
tent of the affection, manifestation of fever, pulse, temperature, 
appetite, thirst, stool, urine, etc. 

*' The first line of symptoms will give the most characteristic 
indications, as they contain the individual peculiarities; while 
the latter ones are of more general value, and will only confirm 
or rarely modify our choice of the remedy. Still, they must all 
be weighed according to their prominence and mutual relation. 

" To begin at the beginning, I must say that two grave mis- 
takes are frequently made with aconite, the remedy par excel- 
lence ' when the fever runs high.' 

" The second mistake is to change aeon, for another remedy 
when the fever decreases and the cough becomes loose. 

" So long as aeon, produces such a favorable change, why 
not continue it, as we would any other drug under the same 
circumstances? But if our patient has received enough of it, 
and is improving, then stop all medication, and, if necessary, 
give sac. lac. 

" The indications for aeon, should be more precise than those 
furnished by high fever, dry cough, and great restlessness, which 
it shares with other remedies. There should be present a short, 
dry, hacking, or sometimes ringing cough, worse after drinking 
cold water, and lying on either side, while lying on the back 
partially relieves it. The child may grasp its throat every time 
it coughs. The breath is hot, while the mode of breathing has 
nothing characteristic ; it may be labored and anxious, or quick 
and superficial, or deep, slow and sighing. 

" The character of the pulse is very important for aeon. In 
inflammations it is hard, full, and strong. Restless sleepless- 
ness, continual tossing about, with eyes closed. 

''The quantity of the urine is greatly diminished even to re- 
tention. The urine is hot, dark-red, brown and turbid. The 
child is restless before urinating, and frequently cries during 
the act. 

" The restlessness of chamomilla is much more of a nervous, 
passionate character ; the movements are rather of a spasmodic 
nature. The child works itself into a passion, at the height of 
which it will be seized with a long-lasting, exhausting cough. 
The cough will also be dry (as in aeon.), but only so about mid- 
night, being looser in the daytime. With the cough, we notice 
a rattling of mucus in the trachea. The pulse is much smaller 
and weaker than in aeon.; frequently unequal, changing from 
weak to tense and accelerated. The urine is also scanty and 



574 THE DISEASES OF CHILDREN. 

painful, but rather yellow, and its turbidity is of a clay color. 
Cham, is of great value in the bronchitis of teething children. 

^'Another remedy, which I should never like to be without 
in the treatment of this affection, is cina, 

" It is, so to say, of a higher pitch than cham., and simulates 
more threatening conditions. The child is uncontrollable, but 
deathly pale constantly, whether quiet, coughing, or crying. 
It screams when approached or touched. The breathing is shorty 
at times interrupted, imitating Cheyne-Stokes respiration. The 
cough is like that of aeon., dry, short, hacking, especially at 
night, somet'mes gagging, and the child may seem to swallow 
something immediately after coughing. Unlike the two reme- 
dies above-mentioned, the urine is copious, and passed fre- 
quently. As soon as the child falls asleep, it starts, screams, 
and kicks. Convulsions may be apprehended at any moment. 

" In such apparently alarming conditions, a few doses, even 
a single dose, of cina, 30th or 200th, will change the scream to 
a quiet repose. The physical signs may point to phosphor, or 
tartariis enieticiis, but when the above nervous symptoms are 
present, cina will have to pave the way for their use. Such 
conditions are not unfrequent in nervous children, even when 
free from the intestinal irritation of worms. 

" The most suitable remedies in bronchitis are undoubtedly 
phosphorus and antimonium tartaricum. The indications for 
both are too well known to need repetition here. Still, in re- 
gard to phos., I should like to call attention to a peculiarity 
diametrically opposite to lachesis. ' The cough and condition 
of the patient are always better after sleep.' This is especially 
valuable when the disease has become chronic, and a barky^ 
croupy cough remains. 

" Phos. is indispensable in the true capillary form, mixed 
with broncho-pneumonia. The pulse and temperature run high. 
The pulse is full and hard, as in aconite, but the time for this 
latter remedy has passed. Also in cases where prostration is 
marked, and the pulse becomes small, weak and frequent, phos. 
is highly valuable. It must then be repeated according to the 
intensity of the symptoms, every five to thirty minutes, extend- 
ing the interval when improvement sets in. 

''About ant. tart., I have frequently heard the remark, that 
it is indicated only when fair rales (in the smaller tubes) are 
predominant, while ipecac is said to correspond to the coarse 
rattling (in the larger ones). Hering has it so in his Condensed 
Materia Medica, while in his Guidiyig Symptoms he heavily 
marks under ant. tart., ' Such rattling that it threatens to suffo- 
cate the child. Respiration, with great rattling of mucus.* 
Again, we should remember the characteristic symptom, ' When 



CAPILLART BRONCHITIS. 575 

the child coughs, there appears to be a large collection of 
mucus in the bronchial tubes/ and if we listen to the chest, we 
hear the snoring, coarse, rattling breathing all over that region. 

" The above symptoms all indicate ant. tart., and the physi- 
cal signs in addition, will prove that this remedy is well suited 
in cases where the chest is filled with mucus to the top of the 
throat, and consequently coarse rales prevail. 

" Considering the excessive exhaustion produced by ant. 
tart., we readily understand that it is of high value in impend- 
ing paralysis of the lungs, characteristic of capillary bronchitis 
mixed with broncho-pneumonia. 

" Drowsiness, face deathly pale, bloated or livid, eyes sunken, 
with blue margins ; abdominal, panting respiration ; unequal, 
intermittent breathing during sleep, — all these symptoms 
strongly call for ant. tart. 

'* The ant. sulph. aur., lately advocated again by old-school 
physicians, has been obsolete with them for many years. Do 
not ask them ' Why ? ' 

" Though its proving is yet meager, it acts most charmingly 
in scrofulous children attacked with acute or chronic bronchitis, 
with profuse accumulation of mucus ; especially when they are 
taciturn, obstinate, fretful, and peevish. The appetite is en- 
tirely lost, breath foul, tongue thickly coated. Perhaps the 
two atoms of sulphur, which it contains, more than the ant. 
crud., give it a deeper action on the system generally, where 
the latter drug seems to be indicated, but fails. 

*' IpecacuanJia is differentiated from ant. tart, as follows : 
First of all, the bronchial rales are finer throughout, and if 
coarse, they are not so constant and prominent, as in tart, emet., 
but appear rather with deeper inhalations. The cough of ipec. 
is more spasmodic, and the tendency to vomit is greater with 
this drug. In antimony the tendency to pulmonary paralysis, 
general exhaustion, and collapse is greater, while in ipec, the 
spasmodic character prevails with the prostration. 

*' Many other remedies have been successfully used by differ- 
ent physicians on special indications, as hepar, when the cough 
is croupy, but when, as Prof. T. F. Allen appropriately describes 
it, ' the sharp edge of the cough is broken off.' It is rather a 
choking, phlegmy cough. It is frequently called for after the 
exhibition of ant. tart. 

" The keynote for lycopodium, ' the fanlike motion of the 
alae nasi,' is not a simple rising and falling of these parts, as 
belladonna and some others have it, and which has disappointed 
many ; but the nose is widely dilated, like the end of a trumpet, 
and then forcibly contracted. 

''Arsenicum is another remedy of high value in capillary 



576 THE DISEASES OF CHILDREN. 

bronchitis. Excessive anxiety, as expressed in the face, which 
is earthy gray, sunken, or edematous ; the child cannot find 
rest anywhere, changes continually from bed to lap and vice 
versa; burning heat, with great thirst for small quantities of 
cold water ; these are the well-know characteristics which call 
for arsen. and seldom in vain. 

'' With dulcamara, cJielidojiium, bryonia, gelsemium, eupa- 
torium, rumex, and veratrum viride I have had little ex- 
perience. 

** In conclusion, let me say that there should not be any 
more difficulty in the treatment of capillary bronchitis than of 
any other diseased condition ; that we should not, be misled by 
supposed pathological conditions, nor that we should give pref- 
erence to any drug recommended in the books for such condi- 
tions. We must be guided strictly and only by the facts 
presented to our trained senses and reason, and select carefully 
from the wealth of our materia medica, that drug which alone 
will answer our purpose, though it may never have been 
thought of in that connection before. Let the homeopathic 
physician ever remember ' The more haste the less speed.' " 



CHAPTER IX. 

ASTHMA. 

Definition, — Asthma consists of irregular or periodic attacks 
of paroxysmal dyspnea, with intervals between of entirely or 
comparatively free and unembarrassed respiration. 

The infrequency of asthma among infants and children in 
this country is doubtless the reason that nearly all American 
text-books on diseases of children take no notice of it. Day 
is about the only English author who more than mentions it. 
Goodhart ignores it entirely. West devotes less than a page 
to it, while Underwood, Churchill, Steiner and Niemeyer do 
not even allude to it as a disease occurring in childhood. It is 
surprising, therefore, to read the statement of Hyde Salter that 
''more cases originate during the first decade than during any 
other period of life." He further states that out of 225 cases 
(all ages), 71 dated back to the first ten years of life, and in 11 
of the number, it came on under the age of one year. West 
confirms these observations and cites Lochner, of Prague, and 
Dr. Politzer, as having also frequently met with it in early life. 
According to our own experience, it must be very rare, for we 
have never met with more than half a dozen cases, either at 
the Half Orphan Asylum, at the Dispensary, or in private 
practice. 

It is not a disease likely to be often encountered in dispensary 
practice, for, according to all authorities who make mention of 
it, it is more common in the upper than in the lower classes, 
for reasons which will appear later on. 

Etiology. — The causes which are supposed to enter into the 
production of asthma are divided into predisposing and exciting. 
The predisposing causes are largely hereditary. In rather more 
that two-fifths of all Salter's cases he found distinct traces of 
inheritance, direct or lateral, near or remote. He also found 
the disease much more prevalent among boys than girls — the 
proportion in sixty-three cases being forty-six to seventeen. 
No satisfactory solution of this difference is given. Theoretic- 
ally the figures ought to be reversed, for asthma is generally 
regarded as one of the many and various manifestations of 
what is called the neurotic temperament, or constitution, which 
reaches a higher development in females than males. Among 
D. C— 37 (577) 



578 THE DISEASES OF CHILDREN. 

the exciting causes are those which act directly on the lungs, 
such as bronchitis, either primary or secondary ; whooping 
cough and pneumonia ; the presence of emphysema in the 
lungs, and especially that collapsed condition of certain por- 
tions of the lungs known as atelectasis, occurring from rachitic 
deformity, or from broncho-pneumonia. Enlargement of the 
bronchial glands is also mentioned as a cause of asthma from 
pressure upon the pneumogastrics. Other exciting causes are 
reflex in their nature. Among these are nasal polypi and irri- 
tation of the gastric nerves by worms or indigestible food — 
peptic asthma. Another form of the disease is known as her- 
petic asthma, which arises from certain affections of the skin, 
notably eczema and urticaria. 

West says : '* I have never known eczema to be very exten- 
sive and very long continued without a marked liability to 
asthma being associated with it. It cannot be said, however, 
that the two conditions always alternate, the asthma being 
worse when the cutaneous affection is better; but the radical 
cure of the eczema is usually followed, though often not till 
after the lapse of three or four years, by the cessation of the 
liability to asthma. Uremic, gouty and saturnine subjects are 
quite liable to asthma. Trousseau tells of a boy of five whom 
he saw in well-characterized fits of asthma, and who, two years 
later, had typical gouty arthritis, during the continuance of 
which he was free from his asthma. 

Salter tells of an adult who could produce an attack at will 
by applying cold to the instep. 

Dr. Leila G. Bedell has reported a number of cases of well- 
marked asthma which she considers entirely idiopathic, that is 
to say, unconnected with any other disease, as measles, whoop- 
ing cough, or bronchitis ; but in all of them the neurotic feature 
was well marked. One of them was only affected with an a.t- 
tack " when sitting from daylight through twilight into dark- 
nessT The attacks always occurred immediately after dark and 
were preceded by continued gaping. Another case was al- 
ways preceded by continued sneezing, as if an acute coryza 
were about to set in ; while still another has attacks following 
a severe spell of crying. Dr. Bedell's cases were all girls, her 
experience being contrary to that of Salter and others in this 
respect. In four of her five cases the asthmatic tendency 
seemed to have descended from the grandmother on the 
father s side, and in the fifth case from the grandfather on the 
mother s side — the intervening generation in each case having 
shown no tendency whatever to asthma. 

In all of the cases one type prevailed, viz,, a sensitive, deli- 
cate, nervous organization. After discussing these cases at 



ASTHMA. 579 

length, Dr. Bedell says : " Hence, from my standpoint (regard- 
ing the sympathetic system the seat of the emotions rather 
than the brain), I should regard asthma as preeminently a neu- 
rosis, having its origin in the sympathetic ; and conclude that 
the only relation which the pneumogastric sustains to the dis- 
ease, obtains wholly from its intimate connection with the 
sympathetic through the fibers arising from the sympathetic 
ganglia on the root and on the trunk of that nerve. In the 
treatment of such cases the list of remedies which I have found 
successful narrows itself down to three — namely, gelsemuun 
30X, sambucus 6x, and ipecac 3X. 

" In the case of the child whose attacks were always preceded 
by crying spells, gels. 30X, was the only remedy which ever 
gave relief." 

In many cases of asthma, when the habit is once established, 
the exciting cause is too trifling in many instances to be rec- 
ognized. The attacks occur at all seasons of the year, though 
more frequently in spring and autumn, when colds are most 
prevalent. If the attacks are not exceptionally severe and fre- 
quent, there is a strong probability of their ceasing about or 
before puberty. In two of our own cases, that resisted all rem- 
edies that were brought to bear upon them, the attacks ceased 
spontaneously, one at the age of eleven, the other at twelve. 

Pathology. — All that is known relative to the pathology of 
asthma is summed up in these words of Berkart, '^Asthma, 
therefore, is only one link in a chain of quasi-independent af- 
fections, which commences with inflammatory changes of the 
pulmonary tissue, and terminates with emphysema or bron- 
chiectasis." 

The symptoms of asthma in children do not differ from those 
of the adult. The attack, as a rule, comes on suddenly. The 
face is pale, cyanotic and anxious. The skin is moist and cool. 
There is no fever. The pulse is rapid and often irregular. The 
respiration is slow and labored, expiration being much pro- 
longed ; the chest is fixed in the position of full inspiration, 
with a low diaphragm ; percussion-resonance is increased in 
intensity and area ; on auscultation the respiratory murmur is 
much enfeebled or absent, and sibilant and sonorous rales are 
heard everywhere. The cough, if present, is short and dry. If 
the child is old enough to expectorate, the paroxysm is gener- 
ally terminated by the expulsion of a small quantity of tough, 
viscid mucus. The attacks usually end as they came, the child 
falling asleep, and awaking next morning as well as usual. The 
frequency of repetition is very variable and irregular. 

The prognosis, as above indicated, is usually good. 

Treatment. — Besides the remedies mentioned by Dr. Bedell, 



580 THE DISEASES OF CHILDREN. 

and which are the ones we have ourselves used with the most 
success, there are others which may prove useful in cases where 
these have failed, or where the indications point to them, viz., 
ciipru7n^ veratrtim, aurum broin., staphysagria. arsenicum, bry- 
onia, and hyoscyamus. 

EMPHYSEMA. 

The term emphysema is used to denote an excess of air in 
the lungs — either in the distended cells of the lungs, constitut- 
ing vesicular emphysema ; or into the intercellular spaces, con- 
stituting iiiterstitial emphysema. 

Vesicular emphysema is that form in which the air is still 
contained within the air vesicles, and is by far the most fre- 
quently met with. Only a few of the air sacs may be involved, 
the whole of a lobe, or even, in extreme cases, the entire lung. 
The apices and margins of the base of the lungs are particularly 
liable to be afTected. In emphysema the lungs are increased in 
size, while their elasticity is destroyed. It is not a disease pe- 
culiar to childhood, but may occur at any age. As it is often 
encountered in early life, it requires a brief description. It is 
especially frequent in children who are the subjects of rickets 
and asthma. In some cases, however, it appears to be congeni- 
tal. In vesicular emphysema the morbid anatomy shows only 
enlarged air vesicles, with here and there one which has been 
distended beyond the point of rupture, so that two or more 
sacs are thrown together. This, however, is a rare accident. 
More frequently the walls of the air cells are simply distended, 
their elasticity destroyed, and they resemble a small, inanimate 
bladder more or less inflated with air. Atelectasis is a term 
denoting collapse of the air cells, with the cell walls in apposi- 
tion ; emphysema is its direct opposite. Sometimes the bron- 
chioles or medium-sized bronchial tubes are distended, and lose 
their resilency, which condition is known as bronchiectasis. This 
is so rare a condition as to deserve nothing more than its bare 
mention here, and the statement that it has been known to 
occur as a result of whooping cough, bronchitis or pneumonia. 

In ijtterstitial emphysema (sometimes called interlobular^, the 
connective tissue which binds the lobules together is infiltrated 
with air, which has escaped from the ruptured vesicles, and 
sometimes this is suf^cient to raise the pleura from the surface 
of the lung. There are no real tissue changes in emphysema, 
other than those implied in the foregoing description. There 
is no inflammation, no degeneration of tissue, no catarrh other 
than that which may belong to the bronchitis or the whooping 
cough which preceded the dilatation. The cause of the trouble 



EMPHTSEMA. 581 

may be indirectly traceable to inopportune closure of the glot- 
tis. In pertussis the explosive nature of the cough produces 
a greatly increased pressure on the delicate walls of the vesicles, 
and this is added to, if, at the moment of cough, the glottis is 
closed, as it is liable to be, in efforts at suppression. The re- 
sult is felt in the air cells, which feel the pound of the cough, 
and are unable to resist its force. 

If the opening through which air has escaped is small or soon 
closed, the misplaced air is readily absorbed, and but little 
damage is done ; but if air continues to pass out, it may find 
its way between the lung and the pleura along the trachea, or 
sheath of the vessels, and distend the subcutaneous cellular 
tissue. The rupture of air cells may be due to external injury 
or violence ; or to forced respiration into the air passages of an 
asphyxiated infant. 

It is more common in bronchitis and whooping cough than in 
pneumonia or phthisis. The disease is said to produce hyper- 
trophy of the right heart and cerebral congestion. 

Symptoms. — The chief symptoms are shortness and difficulty 
of breathing. This is increased by any physical exertion, such 
as walking fast or ascending stairs. At first this is only felt 
when some unusual exertion is made, but as the disease ad- 
vances, the breathing becomes permanently accelerated and 
even panting when the patient is sitting still. In mild cases, 
even a true emphysema of short duration may present no recog- 
nizable symptoms during life. Children suffering from emphy- 
sema, do not, as a rule, suffer the same amount of distress in 
consequence, that adults do. The sputum is sometimes tinged 
with blood, from ruptured capillaries in the over-distended air 
cells. The face is apt to be dusky, and in long-standing cases, 
cyanotic. The nostrils are dilated, the voice is weak, and the 
cough feeble. The finger tips are cold and blue. Headache 
and drowsiness are usually experienced. The abdomen is dis- 
tended and as a result of the disease, the liver and spleen be- 
come increased in size. Emaciation is frequently noticed. 

In cases attended with dropsy, tricuspid regurgitation is pres- 
ent. The entire thorax is misshapen, the upper part being 
enlarged, giving it a barrel shape. The ribs lose their obliquity, 
and their anterior extremities are drawn upwards. 

The respiration is peculiar and characteristic. The upper 
part of the chest is nearly fixed, and the diaphragm appears 
passive. The inspiration is short and hurried, from the dimin- 
ished expansion of the chest, and the expiration is wheezy and 
prolonged. Spasmodic fits of coughing are common, especially 
if the bronchial tubes are loaded with mucus. In conversation, 
the child waits to get breath ; if its answers are required quickly, 



582 THE DISEASES OF CHILDREN. 

it stops frequently in the midst of a sentence to get fresh breath. 
When emphysema is compHcated with organic disease of the 
heart, or with confirmed asthma, the prognosis is bad. The 
disease is probably irremediable. But when it occurs as the 
accompaniment of whooping cough, it will gradually pass away 
with the disorder, and the child may grow up without any sign 
of ever having suffered from it. 

This observation of Day's we have repeatedly confirmed. 
Auscultation and percussion yield no satisfactory results in this 
disease. 

Treatment. — From what has been said relative to the cause 
and nature of this affection, but little good is to be expected 
from drugs administered with reference to direct results. But 
great good may be anticipated from indirect treatment, by 
which we mean, treatment addressed to the causes which have 
been active in the production of the diseased condition. 

The patient here, as everywhere, needs the medicine and not 
the disease. The cough must be controlled — hence remedies 
addressed to the cough, are of first moment. Then remedies 
should be addressed to the general cachexia. The appetite 
should be improved ; the general health improved ; perhaps a 
change of air may be advisable ; pulmonary gymnastics and 
massage of the chest are advised. Every precaution should be 
taken to prevent an access of fresh colds, and an aggravation 
of the cough already present. 



CHAPTER X. 

ATELECTASIS (COLLAPSE OF LUNG; FETAL CONDITION OF 

LUNG). 

Two forms of atelectasis are recognized, namely, congenital 
and acquired. In the former variety some portion of the lung, 
more or less, remains unexpanded after birth, and in these por- 
tions the fetal condition is maintained for hours, or in some 
cases, for weeks and months. In the acquired variety, owing 
to some obstruction to the respiratory act, certain portions of 
lung — sometimes an entire lobe — collapse, and being impervious 
to air, the same fetal condition, as in the former case, is pres- 
ent. The congenital variety is usually to be regarded as one 
of the accidents of birth. In some cases it is due to protracted 
labor, to breech presentation, to prolapse of the cord, etc. In 
cases in which no respiratory act has taken place, of course the 
whole of both lungs remains airless, and there is general ate- 
lectasis. In the acquired form, the extent of collapse varies 
from a small area to an entire lobe, or lobes. Various causes 
operate to bring about this condition. It is a very common 
one in infants prematurely born, and is due in such cases to the 
inherent weakness of the child ; it lacks the strength to take a 
vigorous inspiration, and the lungs consequently remain unex- 
panded. Later on, still owing to an excessively feeble state of 
the organism, the air is gradually expelled from the air cells, 
but there is not strength enough to refill them, and collapse of 
the cell takes place. Again, an infant affected with rickets, in 
whom the bones are soft and yielding to atmospheric pressure, 
acquires atelectasis from compression of the lungs. Whooping 
cough, bronchitis and broncho-pneumonia are very often fore- 
runners of this disease, and it frequently comes on suddenly 
and without warning. 

The acquired variety of atelectasis is not confined to infancy, 
but is common to all ages. It is most frequently met with, 
however, at the two extremes of life — infancy and old age. 

It is stated that the portions of lung most apt to be affected 
by pulmonary collapse are the interior margins of the lungs, the 
edges of the lower lobes, and the middle lobe of the right lung. 
In any event, whether the morbid condition is congenital 

(583) 



584 THE DISEASES OF CHILDREN. 

or acquired, the results are the same. The affected portion of 
lung is unexpanded, collapsed, airless. 

Etiology. — In addition to the causes already noted for im- 
perfect or non-expansion of the lungs at birth, there are various 
others mentioned by authorities, such as imperfect develop- 
ment of the respiratory nerve centers of the fetus, which then 
do not respond to the want of oxygen, and no respiratory act 
is attempted. In such cases the child is " still-born." In some 
cases, as in premature detachment of the placenta, or pla- 
centa previa, there is a sudden interruption to the supply 
of oxygen from the maternal blood, which excites violent 
efforts on the part of the child, which only result in inhaling 
blood, mucus, meconium or liquor amnii, which, being drawn 
into the larynx or trachea, produce suffocation and pulmonary 
collapse. 

A very common cause of acquired atelectasis in infants is a 
firm plug of mucus acting as a ball-valve, preventing air from 
entering the air vesicle, while it does not prevent the contained 
air from escaping. In other cases the bronchiole leading to the 
alveoli is occluded by swelling or mucus, and eventually the air 
contained in the vesicle is absorbed and the cell collapses. 
West has pointed out the fact that collapse of the lung may 
occur independently of any affection of the air passages. He 
cites an instance of this kind in which the patient, a little girl 
five months old, died greatly exhausted from diarrhea. There 
was extensive atelectasis of the right lung, but the bronchia 
were pale, and contained no secretions. 

Collapsed portions of lung occupy less space than normal 
lung tissue, and sink below the general level of lung surface. 
As the collapsed areas are generally small in size, it gives the 
affected lung an irregular outline. An atelectatic lung is of 
leaden hue, and when cut, a clear or bloody fluid exudes. It is 
firm to the touch, or perhaps somewhat sodden in consistence, 
like liver or spleen. From its resemblance to ordinary flesh, it 
is said to be in a condition of carnification. 

Symptoms. — When imperfect expansion of the lung exists 
from birth, the physician in attendance, upon that event, need 
have no difficulty in the recognition of the trouble. The heart- 
beat is feeble and irregular, the cry is faint or almost inaudible, 
there are no voluntary movements of the limbs, the respiratory 
efforts' are made only at long intervals, and then are weak and 
desultory gasps ; the color of the child, instead of being dusky 
red, is pale, leaden or cyanotic. If an occasional feeble effort 
to breathe is made, it is accompanied with a moist, rattling 
sound. The infant shows great weakness ; the limbs hang limp 
and motionless ; the eyes are closed and the pupils dull. The 



ATELECTASIS. 585 

lips have a bluish tint. The majority of children born in this 
condition quickly die, although they may live on for hours or 
days. Under favorable circumstances, the respiratory efforts 
become more effective, and are closer together. Finally, a 
powerful inspiration is effected, the face loses its leaden hue, 
and takes on a red or natural pink color, the child utters a loud 
cry, and the pulsation of the heart becomes normal in rhythm 
and volume. 

In acquired atelectasis, the symptoms are similar, but less 
pronounced. It occurs most often in the early period of life, 
and in delicate subjects, who are suffering from whooping 
cough, bronchitis, or some wasting disease, like diarrhea. The 
symptoms are referable to the respiratory function, and are 
mild or severe, according to the amount of lung tissue involved. 
The breathing is hurried and shallow — the inspiration being 
slower and more difficult than the expiration. The pulse is 
quickened and its volume is diminished in direct proportion to 
the amount of consolidation. The color of the skin is dark- 
ened, sometimes to the extent of lividity. The elastic chest 
walls, over the portion of affected lung, yield to atmospheric 
pressure, and are sunken as compared to the condition over 
other portions of the chest, where the lungs are doing compen- 
satory work, and here there may be bulging of intercostal 
spaces from over-inflation of the uncolla|gsed vesicles. Emphy- 
sema, however, is not usually associated with atelectasis. 

In well-marked cases there are evidences of more or less con- 
soHdation or solidification of the lungs, which for a long time 
led this condition to be confounded with pneumonia. 

The dullness on percussion is usually slight, unless there be 
associated with the collapse an abundant pleuritic effusion or 
pneumothorax. There is no inflammatory condition attached 
to atelectasis pure and simple, consequently there is no increase 
of bodily temperature, except as it is associated with other 
febrile maladies. The general state is one of prostration and 
great depression, and after a period varying from days to weeks 
or months, the child generally dies from exhaustion. 

Treatment. — In congenital atelectasis every effort should be 
made to effect a full inflation of the lungs. 

This should be attempted by means of artificially forcing air 
into the lungs; by using the Marshall Hall method of resusci- 
tation ; massage of the chest, and by alternately sousing the 
child into hot and cold water. A draught of cold air should be 
allowed to strike the bare cutaneous surface, which tends to 
arouse the dormant respiratory nerve. In some cases, where 
there has been no special delay in the labor, simply blowing 
in the child's face, or slapping the buttocks with a towel wet in 



586 THE DISEASES OF CHILDREN. 

cold water, is sufficient to excite a deep inspiration and bring 
forth a satisfactory cry. 

Dr. Busy succeeded in restoring life in cases of this kind in 
two instances after all other means had been tried, by what is 
known as the Silvester method of resuscitation in drowning cases. 
This method consists in laying the child upon its back, while 
both arms are slowly and simultaneously raised towards and 
alongside the head, and then replaced and pressed against the 
sides of the chest to expel the air from the lungs. Dr. Francis 
Minot, in Keating's Cyclopedia, thus describes a method sug- 
gested by Schultz, and which he indorses as having proven ef- 
ficient in his hands : " The child being laid on its back, with its 
head toward the operator, is grasped by the hands applied to 
its chest and shoulders in such a way that the head falls back- 
ward, the face towards the knees of the operator, while the 
belly and legs hang down in front. The weight of the head in 
one direction and of the rest of the body in the other, causes 
an enlargement of the chest by traction, with depression of the 
diaphragm, and promotes inspiration. The operator then swings 
the child quickly upward, reversing its position so that the 
head is flexed upon the chest, while the trunk and legs fall 
downward and towards the face, thus compressing the chest 
and expelling the air." 

Faradization has J^een used successfully in some cases, 
but in our own hands it has, for some reason, always failed. 
It should be applied with care, if at all, and only sufficient 
strength of current to incite respiratory effort. In acquired 
atelectasis, the main indications are to overcome the debility 
and exhaustion which are always present, and also the diseased 
condition that has preceded the pulmonary collapse. Change 
of air, removal of the patient to some elevated region, where 
free ventilation and stimulating atmosphere can be had ; good, 
nourishing food, and the judicious use of stimulants will often 
prove beneficial. 

Deep breathing and vocal gymnastics are useful ; the patient 
should be encouraged from time to time to take a deep and 
forcible breath, with a view of expanding the collapsed por- 
tions of the lungs. Sponging the body with cool or cold water 
is useful, accompanied with brisk friction with the hands over 
the entire body. The internal treatment by means of drugs, is 
of little use, except in the acquired variety. Here the reme- 
dies most applicable will be those already mentioned under the 
head of capillary bronchitis and those suggested in connection 
with broncho-pneumonia. Dr. Ludlam relates a case present- 
ing sudden and alarming symptoms of collapse of the air cells, 
following an attack of bronchitis, in a boy ten days old. After 



ATELECTASIS. 587 

trying other remedies with little or no effect, a grain of tartar 
emetic 2x trit. was put in a third of a glass of water, and doses 
of it given at short intervals. The result was almost instan- 
taneous relief, and the child recovered. Dr. L. expresses the 
belief that antimonium tartaricum is practically and patholog- 
ically specific for post-natal collapse of the air cells. Nitro-glycer- 
in 3x, in weak solution, should be a valuable remedy in this 
condition, from its powerful stimulating properties. 

When the collapsed state is consequent on pressure from dis- 
tension of the pleural cavity, the pleuritic affection itself must 
be attended to before any expectations or hope need be enter- 
tained of compressed pulmonary tissue resuming its normal 
condition and function. 



CHAPTER XI. 

PULMONARY PHTHISIS. 

Phthisis may be defined to be that form of tuberculosis 
which principally affects the pulmonary tissues. It is also fre- 
quently referred to as acute pulmonary consumption. In our 
chapter on Tuberculosis, we endeavored to draw a distinction 
between general tuberculosis, in which caseous nodules were 
found widely disseminated throughout the glandular structures, 
and that form of the same pathological process, which is man- 
ifested when the lungs are assailed. It is no longer necessary 
to discuss the question whether tuberculosis and phthisis are 
identical. Their identity is now almost universally admitted. 
When tuberculosis affects the lungs, however, we have a differ- 
ent train of symptoms; the disease runs a shorter and some- 
what different course, and the practice is a proper one to give 
it special consideration. As regards the age among children 
when pulmonary phthisis is most apt to show itself, there is 
much diversity of opinion. According to Portal, it may be 
congenital. Trousseau observed it quite often in the first years 
of life, while Papavoine asserts that it is frequent only between 
four and five years of age. James Clark found it frequently 
after the second year, while others deem its occurrence before 
the age of five or six as rare. 

According to Baginsky, eight per cent, of all cases of pul- 
monary tuberculosis are met with prior to the tenth year. 

About all that need be said under the head of etiology of 
phthisis has been said when speaking of acute tuberculosis. 

It is by no means certain that the disease is transmitted di- 
rectly from parent to child. It is more probable that heredity 
begins and ends with " the propagation of a peculiar debility 
or inefficiency of either the whole organism, or special organs, 
which deprives the individual of its power to resist injurious in- 
fluences or deleterious invasions." There is unquestionably an 
inherited predisposition to pulmonary disease, which is some- 
times very early noticeable, but in more cases is only manifested 
as the child approaches maturity. Then we observe ** the rela- 
tively great height of the body as compared with its weight, 
the thin bones and muscles, transparent and delicate skin, scanty 
subcutaneous tissue, the extensive nets of superficial veins, the 
(58«) 



P ULMONA R r PH THIS IS. 589 

flushed or pale cheek, pale mucous membranes, flat chest, with 
short sterno-vertebral diameter, large intercostal spaces, short- 
ness of costal cartilage, either congenital or resulting from 
premature ossification, the marked depth of the supra- and intra- 
clavicular fossse, the prominent scapula, the clubbed finger 
ends, and the feeble heart." 

The phthisical conformation in typical cases has been spoken 
of by nearly all authors, ancient and modern, and yet it is not 
always safe to predicate a diagnosis on mere appearances. We 
are apt to be frequently deceived. It would often puzzle a 
close observer to distinguish a rheumatic from a tuberculous 
subject. Two types are met with that are quite opposite, and 
yet both suggestive. One is the pretty and intelligent child, 
with well-formed but light skeleton, soft hair, long eyelashes, 
peach-like skin, good nails and teeth and long fingers. Then 
there is another type of coarser grain, the pale, sallow, stunted, 
thick-skinned and ill-favored child who goes the same way, but 
by a somewhat modified route. The shape of the chest is 
sometimes quite characteristic. Heilier describes three typical 
forms: (i) the long, circular chest; (2) the long chest with 
narrow antero-posterior diameter ; (3) the long, pigeon-breasted 
chest. 

In a general way the tubercular chest may be said to be small, 
with the apices contracted. 

In children the apices of the lungs do not exhibit signs of 
the initial lesion in phthisis nearly so often as is the case with 
adults. The tuberculous infiltration is more disseminated 
through the pulmonary tissues, and disease foci are quite as 
apt to be found at the base of the lung, or in the lower lobes, as 
at the apices. This is accounted for by the fact that in chil- 
dren a bronchitis or a pneumonia, affecting by preference the 
lower parts of the respiratory field, is commonly the precursor 
of the tubercular disease. Then again, the lungs of phthisical 
children do not show those cavities that are so frequently found 
in adults. The disease runs a more acute course, and before 
cavitation of the lungs has advanced to any great extent, the 
disease has taken a change of venue to the meninges of the 
brain or to the mesenteric glands of the abdomen. 

Symptoms. — Without discussing at length the varieties of 
pulmonary phthisis, it may be said that in many respects the 
symptoms do not materially vary in childhood from those ob- 
served in mature life. Still, there are some essential differences, 
which will be apparent as we proceed. In the early stages of 
the disease, the symptoms are often quite obscure. The cough 
may be short and hard, dry and hacking, or loose and easy. It 
is often so trifling as to be overlooked. The child is pale and 



590 THE DISEASES OF CHILDREN. 

thin, with a capricious appetite. The bowels are irregular and 
suggestive of worms. These derangements are apt to receive 
little attention, being regarded as temporary and inconse- 
quential. 

If a number of careful examinations are made, however, it 
will be found that the evening temperature is raised, with a 
remission in the morning, which may be so intense that the 
temperature is normal or subnormal. The skin is flabby, waxy, 
yellowish or covered with pityriasis. In infants the voice is 
thin, and the cry is low or inaudible. 

The languor, weakness and general debility are marked and 
progressive. The physical signs, especially in the early stages 
of the disease, are usually very ambiguous. The signs are sub- 
ject to such variation, that only a frequent repetition of exam- 
inations will enable one to confirm a positive diagnosis. There 
is a lack of constancy in the symptoms, which is more marked 
when the disease begins at the root of the lungs, because for 
some time it will be covered by vesicular structure, which will 
obscure auscultation and percussion and confuse the data upon 
which alone precision can be based. 

Perspiration, which is so constant a symptom in the adult, 
and which is so exhausting, is equally as frequent and intense 
in children. It usually begins about midnight, or soon after, 
and increases the tendency to emaciation. Respiration is more 
rapid than normal, and is superficial in character. The disease 
is well advanced, as a rule, before auscultation and percussion 
reveal any serious changes in the lungs. In some cases, there 
are one or more areas of dullness, but this is by no means 
pathognomonic, for such areas may come from more interstitial- 
inflammatory hyperplasia, or from collapse of small portions of 
lung. Slight cavernous breathing may be present from dilata- 
tion of a bronchus, as well as from a small phthisical cavity. 
When cavernous breathing arises thus from a dilated bronchus, 
it is more permanent than when produced by a small cavity, 
which may fill up with mucus or pus, in which case this charac- 
teristic sound may disappear. Hemorrhages from the lungs are 
rare in children, more rare, indeed, in phthisis than in whoop- 
ing cough. In the latter affection some spitting of blood is 
not infrequent, and serious consequences may arise from blood 
coagulating in the finest bronchioles, causing local collapse of 
the lung, and broncho-pneumonia in consequence. 

Complication. — Pleurisy, usually of fibrinous character and of 
localized extent, is a very common and painful complication. 
It may occur early in the disease, especially if bronchitis or 
broncho-pneumonia has preceded. In other cases it may not 
appear until the disease has made considerable progress. 



PULMONART PHTHISIS. 591 

In children in whom the disease is running a chronic course, 
we have the same comphcations as are witnessed in adults, 7/z>..- 
lardaceous disease of the viscera, fatty liver, tabes mesenterica, 
and intestinal or laryngeal ulceration. 

Death occurs in most cases in very young children, through 
the outbreak of a general or acute tuberculosis, and the ex- 
tension of the disease to the brain and its membranes. 

Prognosis. — It is doubtless true that pulmonary phthisis is in 
many cases susceptible of amelioration. It is also undoubtedly 
true that under favorable circumstances, and in cases where the 
disease has made but little progress, recovery is sometimes pos- 
sible. Favorable cases are those in which heredity cuts but a 
small figure, or no figure at all, and where the disease is super- 
induced by a primary disease, such as whooping cough, pneu- 
monia, bronchitis, or a limited condition of atelectasis. Some 
cases of pulmonary phthisis must recover, hQC3.\is<d post-mortem 
examination of the lungs of children and adults, dead of some 
other disease, often reveals the cicatrices of old inflammations 
and cavities of unmistakable tuberculous origin. It is no un- 
common thing to find in necropsies chalky concretions, calcare- 
ous deposits, and old adhesions which mark the site of former 
specific disease, from which the patient has recovered. It may 
be accepted, therefore, as certain that tubercular disease is 
sometimes amenable to treatment. 

At the same time, it must be remembered that cases may 
ameliorate for a time, and then suddenly develop meningitis or 
general tuberculosis, with fatal results. 

It must be borne in mind, also, that if cases do not show any 
tendency to improvement, the course of the disease in children 
is habitually shorter than it is in adults. 

Treatment. — The successful treatment of pulmonary phthisis 
must necessarily be largely hygienic and circuitous. 

There are no drugs having the power to directly arrest the 
progress of tubercle. Good feeding Ib^d good air are primarily 
essential. And just here we are ^met oftentimes with unsur- 
mountable obstacles. The appetitf is capricious, or the 
stomach intolerant of such articles ofTood as the requirements 
demand. Vomiting is easily excited, and fats which are neces- 
sary to antagonize waste cannot be taken. A diet rich in fats 
is very desirable, if it can be borne. These children should be 
encouraged to eat plentifully of milk, cream and fresh eggs. 
Rare beef and mutton, or the expressed juice of either, is very 
rich in nutrition. Stimulants in small quantities are of unques- 
tioned value. Every attention must be given to the general 
health ; the tendency to diarrheas must be carefully guarded, 
and plenty of fresh air is an absolute necessity. The rooms in 



592 THE DISEASES OF CHILDREX. 

which the child lives and sleeps should be well ventilated. If 
the mother is not perfectly healthy and a good nurser, a wet 
nurse should be secured, or in lieu of this, suitable artificial food 
should be substituted. One of the best foods for these cases 
is composed partly of proteinol, which is a compound of pure 
beef fat, eggs and sherry wine. 

Cod-liver oil in some form has a well-earned reputation in 
the treatment of phthisis. There are preparations now in the 
market in which the taste of the oil is so disguised that the 
most sensitive palate can scarcely detect it. Combined with malt, 
ormaltine, of which there are numerous brands, it will answer a 
good purpose if not too laxative. 

There are cod-liver oil biscuits in which the taste of the oil 
is elegantly concealed ; and almondized oil, and capsules, any 
of which is well calculated to overcome fastidiousness. But 
infants and young children do not usually object to the clear 
oil, if well refined and pure, and the nearer we get to the crude 
oil, other things being equal, the better. 

But the crowded city or town is no place for a child afflicted 
with tuberculosis. A place in the country should be chosen 
Avhere the air is dry and plenty of opportunity can be had for 
out-of-door living. The skin should be kept in an active and 
healthy condition by frequent sponge baths, combined with 
brisk frictions (massage). When gastric catarrh is present, it 
should receive immediate and persistent attention. It is 
thought by many that inhalations of turpentine, eucalyptol, 
menthol, tar, etc., are of benefit. We have never been able to 
satisfy ourselves of any permanent good from them, although 
they sometimes seem to produce temporary amelioration. 
Even this is something. Sometimes the cough may be allayed 
somewhat by simple means in addition to the homeopathic 
remedy. Thus, sipping from time to time a little glycerin 
and water, or glycerin, rock candy, and dilute whisky, gum- 
arabic water, Iceland-mg>ss tea, flax-seed tea, made quite sweet 
with rock candy ; or letting a little vaseline or cocoa butter dis- 
solve in the mouth. 

For night sweats, sponging the body over with vinegar and 
water, or what is more pleasant, acetic or sulphuric acid with 
cologne and water, at bed-time, for several nights in succession 
has often a happy effect. Small doses of picrotoxin 3X at bed- 
time, is strictly homeopathic. Sometimes with older children 
a tumblerful of milk or buttermilk works well. 

Medicinal Treatment. — To give the indications for all the 
remedies which may be of use in this affection, in all of its stages 
and phases, is out of the question. The list of the leading ones 
is all that space will permit. For others, the reader is referred 



P ULM0NAR2' PHTHISIS. 593 

to pages 512, 514, where an extensive repertory of cough reme- 
dies will be found, and also to the chapter on Pneumonia and 
Bronchitis. 

Antimonium tart. — Cough short, shrill, loose, and rattling, 
aggravated at night and followed by nausea, vomiting and 
dyspnea; excessive restlessness; prostration ; chest full of loud, 
rattling mucus. 

Arseniaun. — Great emaciation, weakness and prostration; 
intense burning pains in stomach, with intense nausea and 
vomiting ; excessive thirst, drinks often, but little at a time ; 
breathing very difficult ; diarrhea, stools dark and acid, ex- 
coriating anus and nates; burning, shooting stitches in lungs. 

Belladonna. — Intense congestion of head, with violent, throb- 
bing headache; face red and hot; carotids visibly throbbing; 
cough dr}^, violent, hollow and spasmodic, aggravated by cold, 
motion and at night ; voice husky and very hoarse ; larnyx 
painful, swollen, and inflamed ; sweat on covered parts ; cramp- 
like pain in upper part of chest. 

Calcarea carb. — Cough dry, short and hacking, worse even- 
ings and when lying down ; expectoration of thick, yellowish, 
offensive mucus, sometimes tinged with blood. Especially 
useful in light-haired, plump children of a scrofulous diathesis; 
calc. phos. useful in same cases, calc. iod. in tubercular patients. 

Drosera. — Violent paroxysms of cough following each 
other so rapidly that patient loses his breath ; cough dry, hard 
and spasmodic, and followedby nausea and vomiting, aphonia; 
cough aggravated at night and when lying down ; breathing 
rapid and oppressed ; alternate diarrhea and constipation. 

Ferritin met. — Rough, hoarse voice ; dyspnea ; small, weak 
rapid pulse ; coughs up bloody mucus or pus in mornings ; 
cough dry and rasping at night ; epistaxis ; great emaciation, 
weakness and prostration ; voracious appetite, with extension 
of abdomen ; stools sudden, watery and painless. Especially 
useful in tuberculosis. 

Hepar siilpJi. — Cough deep, rough, barking and excited by 
the least cold striking the body ; rattling of tenacious mucus in 
chest; almost complete loss of voice; raw, scraped feeling in 
throat, with sensation as if splinter were sticking there, worse 
on swallowing; chilliness in open air; high fever with perspira- 
tion ; sweats on slightest exertion ; stitches and pains in palms 
of hands and soles of feet. 

Ipecac. — Audible, coarse rattling of mucus in chest ; in- 
tense nausea and long-lasting vomiting ; dyspnea, with short, 
wheezing respirations ; paroxysms of violent, convulsive cough- 
ing, so violent that child turns blue in the face and becomes 
rigid ; paroxysms of cough cause nausea and vomiting. 
D. C— 38 



594 THE DISEASES OF CHILDREN. 

Phosphorus. — Voice hoarse, husky and rough, cannot speak 
above a whisper mornings ; short, dry, convulsive metallic 
cough ; dyspnea, with pain in chest ; expectoration of bloody, 
frothy, tenacious, purulent mucus ; rawness in larynx, with dif- 
ficult expectoration ; palpitation of heart ; pulse small, full, hard 
and rapid, or weak and compressible ; extreme emaciation and 
weakness ; loss of appetite, with nausea and vomiting ; diarrhea, 
stools watery, green and streaked with blood. 

Pulsatilla. — Hard, dry cough at night, but loose and moist 
during the day, aggravated by warmth, and when lying down ; 
difficult expectoration of thick, yellow, saltish mucus ; thirst- 
lessness ; cannot retain fatty foods, vomits them as soon as 
eaten ; diarrhea of green, slimy mucus, or feces mixed with 
mucus, preceded by rumbling; involuntary micturation in little 
girls, especially while coughing. Especially useful in light- 
complexioned children. 

Saiiguinaria. — Breath and expectoration exceedingly offen- 
sive ; throat sore, dry and feels as if denuded ; cough dry and 
hacking ; severe dyspnea and difficult expectoration ; pain in 
right chest, extending to shoulder ; circumscribed redness of 
one or both cheeks ; hands cold, with ulcers forming about the 
nails ; loose stools followed by flatus. 

. Sulphur. — Weakness, with bruised pain in upper part of 
chest ; stitches in chest, extending through the shoulder and 
back, worse on moving and when lying down ; aphonia ; cough 
dry, short and violent, with expectoration of purulent mucus ; 
dyspnea; hemoptysis; profuse nocturnal perspiration ; itching 
in rectum, with soft stools ; no appetite ; scrofulous subjects 
with boils, abscesses and enlarged glands. 



CHAPTER XII. 

PLEURITIS (pleurisy). 

Pleurisy is an inflammation of the pleural membrane, 
attended in all cases with an exudation into the pleural sac of 
serum or sero-fibrinous fluid, which has a strong tendency to 
become purulent. It may be primary or secondary, acute or 
chronic, circumscribed or general. It is less frequent in chil- 
dren than adults, but is by no means rare even in young infants. 
It affects the two sexes in about equal proportions, although 
some authorities have noticed a slight preponderance in boys. 
In Goodhart's experience, empyematous pleurisy affected the 
left side more often than the right, in the proportion of four to 
one. In uncomplicated cases — that is to say, when not asso- 
ciated with phthisis, pneumonia, or septicemia — it is nearly 
always unilateral. The pleurisy of childhood is more apt to be 
purulent than sero-fibrinous. 

Etiology. — Primary pleurisy is most common in the spring 
and fall, when the weather is changeable, and ordinary colds 
and catarrhs are prevailing. Children who are enfeebled by 
previous illnesses, or neglect, or whose constitutions are below 
par by reason of hereditary influences, are most subject to the 
disease. *' Taking cold " is probably the chief cause of the 
affection in its primary form. 

Secondary pleurisy is due to a great variety of causes. 
Sometimes a trifling bruise on the chest will cause it. It is 
frequent in acute nephritis, whether scarlatinal or otherwise. 
It is a common complication of tubercular disease of the lungs, 
bronchitis, bronchiectasis, disease of the bronchial glands, 
pneumonia of both kinds, pericarditis, scarlatina and acute 
rheumatism. It is frequently seen in connection with diseases 
below the diaphragm, such as peritonitis, appendicitis and 
affections of the liver and spleen. Probably there are many 
cases of pleurisy that cannot be traced to any recognizable 
cause, and which must, therefore, be classed as idiopathic. 

The pathology of infantile pleurisy does not differ from that 
of adults, except in the greater tendency in children for the 
exudation to become purulent. The exudation in some cases 
is nearly all fibrinous, gluing the lung to the thoracic wall, and 
forming firm adhesions, which may last a lifetime. These are 

(595) 



G96 THE DISEASES OF CHILDREN. 

the cases which are called '' dry pleurisy." In autopsies such 
adhesions are frequently found, which had not attracted atten- 
tion during life. In other cases, the effused liquid consists of 
serum, leucocytes, and pus cells. Occasionally, though very 
rarely, blood is effused, constituting what is known as hem- 
orrhagic pleurisy. The liquid is usually transparent, rich in 
albumin, and is of a light yellow or greenish tint. When drawn 
off with an aspirator, it coagulates spontaneously into a soft, 
jelly-like mass. 

The amount of fluid which is exuded in some cases of pleurisy 
is enormous. In the case of a child twenty-two months old, a 
pint and a half of fluid was found in the left pleural sac. Ziemssen 
records a case of a girl three years old, at whose autopsy two 
and a half pounds of fluid were found in the right chest. Hey- 
felder removed by thoracentesis six pints of pus from a boy of 
six years. Such enormous quantities as these are very excep- 
tional. Sometimes the exploratory needle fails to find any ex- 
udation at all, the effusion being of the fibrinous variety, and 
being only sufficient in amount to agglutinate the pleural sur- 
faces. It is not common to find more than a few ounces, except 
in rare instances. J. Lewis Smith says that at the age of four 
months, three ounces of fluid are sufficient to produce complete 
collapse of the lung, and it is stated that this same amount in 
a child a year old will give rise to well-marked flatness on per- 
cussion. Any considerable amount of fluid in the pleural cav- 
ity must, of necessity, produce compression upon the contigu- 
ous lung, and when occurring in the left chest, it may seriously 
embarrass the action of the heart. 

The heart itself may be pushed into the left axilla, or crowded 
over to the right of the sternum. The natural tendency of the 
effused liquid is to press the ribs apart and to produce a bulg- 
ing of the intercostal spaces ; but in young infants, the lungs 
collapse so readily from pressure, that but little distension may 
be noticeable, unless the chest is half full of fluid. Where the 
effused liquid is sero-fibrinous, much of it is ultimately ab- 
sorbed, while the remainder is organized into the adhesive 
bands before alluded to, which bind down the lungs, sometimes 
to the extent of producing deformity ; in other cases of milder 
type and trifling exudation, no serious effects are experienced. 
It is doubtful if purulent effusions are ever absorbed. They 
either cause the ultimate death of the patient, or in more favor- 
able cases, the pus is discharged, either into a bronchus or out- 
wardly by way of an abscess. Cases have been known where 
the emphysema has caused peritonitis, a lumbar abscess, or has 
pointed into the esophagus. 

Symptoms. — Pain, which is of such a marked and definite 



PLEURITIS {PLEURISY). 597 

character in adults affected with pleurisy, is more variable and 
of less significance in infants and children. In some instances 
the pain is intense, so that respiration is restricted, causing the 
child to hold his breath, and to fix the diaphragm, so that the 
breathing becomes abdominal rather than thoracic. In other 
cases, and these are more common, the pain is distributed over 
the subscapular, subclavicular, and soon over the umbilical and 
hypogastric regions. There is, however, great hyperesthesia 
over the affected areas, a sensitiveness to touch which comes 
from an implication of the intercostal nerves. This cutaneous 
sensitiveness in many cases constitutes the bulk of the subjec- 
tive symptoms. No acute pain of a local kind is complained 
of in many cases, unless it is inquired for, and even then it is 
but vaguely indicated. 

The acuteness of the symptoms in the outset is exceedingly 
variable. In some cases, especially in children past the denti- 
tion period, there may be chilliness, headache, fever, and oc- 
casionally in younger children, convulsions. Vomiting is 
sometimes met with ; in short, the initial symptoms are so 
variable that in the absence of lateral pain the diagnosis is apt 
to be obscured. Cough is not an essential symptom in pleu- 
risy, although it is commonly present. In contrast with these 
mild and doubtful cases, there are many who experience sudden 
and violent symptoms of unmistakable import, such as violent 
pain in the side, sharp in character and cutting like a knife, or 
incisive and piercing like a dagger. Such cases are apt to be 
pneumonic as to their cause (pleuro-pneumonia), and the effu- 
sion is apt to be purulent from the beginning. 

The temperature in pleurisy is subject to great variations. 
Mild cases may have none at all, worth recording. In other 
cases the thermometer may register as high as 103°, or even 
higher. The average temperature in pleurisy is probably not 
over ioi°-i05° Fahr. In mild and medium cases the tempera- 
ture falls as soon as effusion is complete, that is to say, within 
twelve to forty-eight hours. If prolonged beyond this period, 
there is likely to be pneumonia present as well as pleurisy. 

In purulent pleurisy — that is to say, in nearly one-half of all 
cases — there is sudden and progressive emaciation. This is often 
rapid and extreme, and occurs in cases in which the onset is 
mild and the symptoms vague, as well as those which are of 
m.ore violent nature. In idiopathic cases the symptoms are 
usually more definite and pronounced than in cases following 
some other disease. Indeed, as a secondary affection, pleurisy 
is commonly very insidious, and unless under the eye of an 
alert physician, may escape notice until purulent effusion has 
made serious progress. 



598 THE DISEASES OF CHILDREN. 

In some cases there is pallor of countenance and a puffiness 
of the face, suggestive of Bright's disease. In such cases an 
examination of the urine will serve to avoid mistakes. In cases 
where there is great emaciation and much general prostration, 
there may be no elevation of temperature, except in cases 
where the pus has been evacuated, either spontaneously or by 
operation. In these latter cases, a reformation of pus is imme- 
diately followed by a rise of temperature. Diarrhea and sweat- 
ing are also indicative of pus formation, either primarily or 
after operation. As a rule, in mild or moderately severe cases, 
the temperature runs a pretty regular course, being somewhat 
higher in the evening, but not showing any erratic rises, unless 
caused by pus. 

Goodhart calls attention to a negative sign which should be 
borne in mind in the considera|:ion of all doubtful cases, viz., 
the absence of any indications of distress in breathing. He 
says : ** Such a thing might, otherwise, be thought impossible 
with one or other side of the chest full of fluid. Yet not only 
may this be so, but even the heart may be considerably dis- 
placed without symptoms. This is noticed in the more chronic 
cases, and is not difficult to explain. A like phenomenon is 
present in many cases of phthisis, and it is dependent in great 
part upon the compensation which takes place as the disease 
progresses, the emaciated body requiring diminished action of 
the lung." 

Physical Signs. — There are certain differences in the physical 
signs of pleurisy occurring in children and adults. In young 
infants these differences are usually very marked. In the com- 
mencement of an attack there is a diminution in the movement 
of the chest walls on the affected side, due to the patient's in- 
stinctive efforts to repress the respiratory action on that side, 
in order to lessen the pain. The respiration, is, therefore, 
largely confined to the unaffected side, and is hastened in con- 
sequence. 

After effusion has taken place, the pain abates, and the res- 
piration is less accelerated than at first ; indeed, it may be 
nearly or quite normal. The bulging of the intercostal spaces, 
and the consequent inequality of the two sides, is made much 
of by some authors, but, in fact, in infants, even where there 
is a large amount of exudation, the bulging is often so trifling 
as to be practically inappreciable, either to sight or measure- 
ment. This is probably due, in most cases, to the collapse of 
the thin borders of the lung and semi-collapse of, perhaps, the 
whole lung on the affected side. This is very apt to occur in 
weakly infants, and especially those who have been reduced by 
previous sickness, even when there is no obstruction to the 



PLEURITIS {PLEURISr^. 599 

entrance of air to the lungs. It is brought about by the pressure 
of the effused liquid, so that the lung recedes from the ribs and 
becomes lessened in actual size, more than enough to compen- 
sate for the space occupied by the fluid. In children with 
strong vocal organs, vocal fremitus will not be found over the 
seat of effusion, but will be marked in the axillary, suprascap- 
ular, infraclavicular, or mammary region, where the compressed 
lung comes in contact with the walls of the chest. 

When there is fluid at the base of the chest, the apex reso- 
nance on the affected side will be modified and have a high- 
pitched, tympanitic note, very different from the natural, deep 
resonance of health. It should be borne in mind, however, 
that percussion does not afford the same degree of accuracy in 
determining the amount of fluid as in adults, because the vi- 
bratory movements of the chest are more easily set up, and 
the sonority of the lung much more easily brought out, and 
there is a much readier development of the tympanitic quality of 
resonance. Indeed, it is only in the later stages that we are 
able to determine, by percussion, the outlines of a large effu- 
sion, and the degree of displacement effected by it of adjacent 
organs. The physical signs to be determined by means of the 
stethoscope are quite inconstant in infancy, and in all pulmo- 
nary affections are so variable that no two observations are likely 
to correspond. The friction-rales, which are so noticeable in 
adult pleuritis, may be altogether wanting in infants, until after 
absorption has begun. 

The real friction sound may be heard in some cases for a 
brief period, and then it may disappear for a time, to recur at 
some later stage of the disease. It is never present when the 
accumulation of liquid is sufficient to prevent contact of the 
surfaces. In pleuritic patients under five years, the ausculta- 
tory sounds are not modified, as in older persons, by the in- 
crease and decrease of the liquid. In such cases, it is rare not 
to be able to recognize the respiratory murmur when the ear 
or the stethoscope is placed over the effusion. It may have a 
weak and far-away sound, but it is still there. This is due to 
the small size of the chest, and the consequent ready transmis- 
sion of sound from the center of the thorax to its periphery. 

If the inflammation be chiefly plastic, or the exudation of 
liquid proceeds slowly, and its quantity be small, the respira- 
tory murmur may be vesicular, though faint and distant, dur- 
ing the whole course of the attack. Sometimes, when the 
murmur is vesicular in the greater part of the lung, broncho- 
vesicular or bronchial respiration is heard over a limited area, 
where the effusion happens to be sufficient to produce requisite 
compression of the lung. 



600 THE DISEASES OF CHILDREN. 

Diagnosis. — Sometimes a mere inspection of a patient suffer- 
ing from pleurisy, may be sufficient to at least suggest the 
nature of the trouble. The face in a typical case is expressive 
of pain, the brow is wrinkled, and the lips compressed. The 
rhythm of the respirations is broken, and they are irregular and 
jerking ; as far as possible they are repressed on the affected 
side and correspondingly increased on the well side. The rate 
is increased to meet the demands of restricted oxygenation, 
and remains abnormally rapid throughout the course of the 
disease. When the pleurisy is on the left side, and the effusion 
is sufficient to affect the position of the heart, the absence of 
its apex beat from its normal place, is a diagnostic sign of much 
importance. A misplaced heart apex, accompanied with acute 
symptoms, should always be looked upon with suspicion in 
this connection. When the pleuritic inflammation is circum- 
scribed, and attended with but little exudation, the diagnosis 
is often attended with much difficulty. The prominent symp- 
toms in the commencement are nearly identical with those of 
pneumonia. Still there are essential differences. In pleurisy, 
both the pulse and the respirations are more accelerated than 
in pneumonia, but the temperature is not apt to be so high. 
The evident attempt to lessen the pain by a partial arrest of 
the respiratory movements, is not seen in pneumonia, nor is 
there in the latter disease that hypersensitiveness of the cuta- 
neous surfaces about the chest that is so marked a feature in 
pleurisy. Another diagnostic feature of value in distinguish- 
ing between the two diseases, results from the fact that the 
pneumonia of children under five is nearly always catarrhal 
(broncho-pneumonia), and is, therefore, preceded by more or 
less bronchitis. It is, therefore, gradual in its approach, and 
not of abrupt development, like an attack of pleurisy. The 
hypersensitiveness of the thoracic walls, which is present in 
intercostal rheumatism or neuralgia, is liable to mislead, but in 
pleurisy the sharpest pains are on one side and remain there, 
while in case the muscles are alone involved, the pains are wan- 
dering and unsteady. Phthisis is not likely to be mistaken for 
pleurisy, even if acute, because in this disease there is usually 
dullness over the apex of the lung, and an absence of respira- 
tory murmur ; while in pleurisy we find at the apex that modi- 
fied resonance before alluded to. This diminished or tympanitic 
resonance at the apex, due to pleuritic exudation at the base, 
is in children almost pathognomonic of pleurisy. The advice 
given by some recent authorities to ascertain whether there be 
exudation or not, and if so, whether it is purulent or not, by 
means of an exploring needle, is only mentioned in order to 
condemn it. Such a procedure is only practiced and sanctioned 



PLEURI TIS— TEE A TMEN T. 601 

by those who have less regard for the life of the patient than 
for so-called " scientific diagnosis." So far as treatment goes, 
it makes no special difference whether the exudation is fibrin- 
ous, serous or purulent. 

The effort of the physician should be addressed to reducing 
the inflammation, and supporting the strength of the patient, 
until such time as nature can bring about resolution. 

Prognosis. — Simple, idiopathic pleurisy is rarely fatal, unless 
complicated with tubercle or pneumonia, pleurisy, even when 
attended with a large amount of serous or fibrinous exudation, 
generally clears up with great rapidity and without leaving be- 
hind any serious or permanent damage. In emphysematous 
pleurisy the prognosis is more grave. A chest full of pus is of 
necessity a serious matter. But such cases are of extreme 
rarity. When they do occur, of course common sense sug- 
gests the propriety of an outward evacuation of the purulent 
matter, by means of puncture and a drainage tube. When 
this operation is resorted to sufficiently early, there is every 
reason to hope for a favorable termination, for antiseptic 
surgery is to-day attended in such operations with but little 
danger. 

Treatment. — There are two remedies of the greatest value in 
the incipient stage of pleurisy, which, given separately or in al- 
ternation, will frequently abort the disease, prevent effusion, and 
afford prompt relief to the most distressful symptoms. They 
are aconite and bryonia. Given early enough, they are often- 
times sufficient alone to terminate the affection and render 
other drugs unnecessary. If, however, the stage of eft^usion is 
reached, which often happens before the physician sees the pa- 
tient, other measures and remedies may be called for. These 
remedies will be mentioned later. As we have seen, the patient 
instinctively tries to lessen his pain by suppressing the move- 
ments of the respiratory muscles on the affected side. But this 
requires a tiresome effort, and unaided is only partially success- 
ful. Much comfort will be experienced by placing a bandage 
of drilling around the chest, and making it fairly snug, but not 
so tight as, to hamper the breathing of the well side. Perhaps 
a better plan than this is to apply adhesive straps over the af- 
fected side, carrying them around from the spine to the sternum, 
and extending them from the axilla to the base of the thorax. 
If the effusion is considerable, and especially if there is reason 
to believe that it is purulent in character, no time should be 
lost in performing the operation of thoracentesis. Wlien per- 
formed with due regard to antisepsis, the operation is practi- 
cally unattended with danger. In any event, the danger is 
trifling when compared to that of empyema. The symptoms 



602 THE DISEASES OF CHILDREN. 

that render this operation necessary are signs of depressed 
vitality, anxious and hurried breathing, weakened pulse and livid 
or cyanotic countenance. 

As heretofore stated, bulging of the intercostal spaces 
affords no criterion by which to judge of the amount of 
fluid in the chest, and there is no positive means of determin- 
ing the character of the fluid, except by using the trocar 
or exploring needle. In some instances the operation may 
need to be repeated, in which case a free incision should 
be made through an intercostal space, and a suitable drain- 
age tube left to keep the cavity free from further accumu- 
lation. 

The method of performing this operation and the precautions 
necessary to be observed, more properly belong to works on 
surgery, to which the reader is referred. 

Remedies. — Aconite in first stage; fever; pain, sharp or lan- 
cinating in character ; anxiety ; restlessness ; dry cough ; 
chills or chilliness ; indeed, all of the symptoms of acute 
pleurisy. 

Bryonia. — May be alternated with aconite or given alone, if 
the first remedy does not quickly show amelioration of symp- 
toms. It is a most useful remedy all through the attack, and 
especially in secondary pleurisy of the plastic variety, which is 
circumscribed in extent. The severe, sharp pains are aggra- 
vated by every motion. There is great thirst, tongue coated 
white, and there is experienced much relief by patient lying on 
the affected side. 

CantJiarides. — Jousset extols this remedy most highly. He 
uses it in the third dilution usually, but if this does not show 
prompt alleviation he descends to the second or first dilution, 
or even the mother tincture. Its special symptoms are : a pro- 
fuse serous exudation, great dyspnea, cough and palpitation of 
the heart, a tendency to syncope with heavy sweats and scanty 
urine. 

Arsenicum. — Great prostration and tendency to collapse. 
The effusion is rapid and copious. In empyema this is the 
prince of remedies. 

Apis mel. — Great dyspnea ; the patient is unable to lie 
down, and feels as if he could not draw another breath. The 
urine is scanty. The action of this drug is in the main very 
similar to cantharis. Both are useful after effusion has taken 
place. 

Hepar sulph. — In chronic cases, and when the exudation has 
become purulent ; there are intermittent paroxysms of hectic 
fever ; the face has a dirty, yellowish tint ; very useful in scrof- 



PLE URI TIS— TREA THEN T. 603 

ulous and lymphatic subjects. This remedy, with arsenicum 
and silicia, will work wonders in many cases. 

Merc, iod, — This remedy is indicated in cases where the 
absorption is slow or negative ; useful in cases where the effusion 
is serous or sero-plastic. It is also useful when the exudation 
tends from the first to become purulent ; chilly sensations ; 
burning heat and copious sweats. See also asclepias, kali iod.y 
hellebore^ lycop., and rhus tox. 



PART X- 

GENERAL DISEASES. 



CHAPTER I. 

CEREBRO-SPINAL FEVER (EPIDEMIC MENINGITIS; MALIGNANT 
MENINGITIS ; SPOTTED FEVER). 

Definition. — Cerebro-spinal fever is a specific, non-contagious 
inflammation of the meninges of the brain and spinal cord, 
having an abrupt beginning and an indefinite termin»ation. In 
non-fatal cases it is apt to be followed by serious and lasting 
sequelae, such as paralysis, total or partial, loss of sight or hear- 
ing, or protracted disease of the kidneys. It has no premoni- 
tory stage, but attacks its victims in the midst of perfect health, 
and is sometimes fatal in a few hours. More often it pursues 
an erratic course, with frequent exacerbations, and terminates 
in recovery or death after weeks or months of suffering. It is 
not confined absolutely to early life, although a large propor- 
tion of cases occur under five years of age. Dr. Sanderson's 
statistics, covering an epidemic in which there were two hun- 
dred and thirty-five deaths, showed that all but seventeen were 
under fourteen years of age. Like the eruptive fevers, it is 
strongly inclined to be epidemic, and in most of the large cities 
it is now endemic. 

History. — Notwithstanding the fact that this disease has been 
found in certain localities in nearly every civilized country, and 
is everywhere attended with frightful mortality, it is scarcely 
mentioned by a single European writer on diseases of children, 
and only one American author seems to have given it more 
than casual attention. This is doubtless due to the fact that 
the disease has been generally confounded with either simple 
or cerebro-spinal meningitis, which is altogether a different 
affection. 

The only clear and full account of cerebro-spinal fever which 
we have been able to find is from the pen of J. Lewis Smith, in 
the sixth edition of his valuable work on the '* Diseases of In- 
fancy and Childhood," from which much of the following 
(604) 



CEREBROSPINAL FEVER. 605 

description has been taken. He says if there were cases of the 
disease prior to the present century they must have been un- 
recognized. 

The history of the disease in this country previous to i860 
is very uncertain and indefinite. Since that date it seems to 
have become estabHshed or ''naturalized " in many cities of the 
United States, and for some years not a week has passed with- 
out the report of deaths from this cause in New York, Phila- 
delphia, Jersey City and Chicago. It is probably also permanently 
established in all of the large cities as far west as San Francisco. 

In New York City a severe epidemic began in December, 
1871, and continued during the first half of 1872. Many of the 
cases which recovered from the attack did so with permanent 
loss of sight or hearing. During 1872 there were seven hun- 
dred and eighty-two deaths from the disease within the city 
limits, most of which were of children. In this epidemic many 
of the lower animals were attacked, especially the jaded horses 
of the city car and omnibus lines. Since this time the disease 
has been firmly established in that city, and the annual mortal- 
ity has ranged from ninety-seven, in 1878, to four hundred and 
sixty-one in 1881. Prof. Stille states that between 1863 and 
1882 it has caused two thousand and forty-nine deaths in the 
city of Philadelphia. It is uncertain when the disease made 
its first appearance in Chicago, but that it is firmly established 
here now is evidenced by the fact that in 1885 one hundred 
and forty-two deaths were recorded from this cause, and it oc- 
cupies a more or less prominent place in the annual mortality 
list since then. The smallest number of deaths in any one 
year since 1885 was in 1887, when there were eighty-one fatali- 
ties, and the largest was in 1891, when the number was three 
hundred and one. It has been observed in Cincinnati, St. 
Louis, Milwaukee, Denver, Detroit, New Orleans and Mobile, 
and it has doubtless obtained a footing in every considerable 
city in the land. 

Etiology. — The direct or immediate cause of cerebro-spinal 
fever is unknown. By some optimistic members of the pro- 
fession, this ignorance concerning its etiology is attributed to 
the scattered localities in which the disease has been observed, 
and to the limited number of cases thus far under observation. 
As we are still profoundly in the dark regarding the causation of 
measles, scarlatina and diphtheria, after centuries of investiga- 
tions, based upon millions of typical cases, it is probable that 
some time will elapse before the exact nature of cerebro-spinal 
fever will be positively known. 

We do know some things, however, about the predisposing 
causes. Thus, while one hundred and sixty-six epidemics 



606 THE DISEASES OF CHILDREN. 

occurred in Europe and the United States in the six months 
commencing with December, only fifty were in the remaining 
six months of the year. Prof. Hirsch collected statistics of a 
large number of epidemics occurring mostly in Central Europe, 
and found that fifty-seven were in winter, or winter and spring, 
eleven in spring, five between spring and autumn, four com- 
menced in the autumn and extended into winter or the ensuing 
spring, while six lasted the entire year. This authority ex- 
presses the opinion that the excess of epidemics in the winter 
months is due mainly to the greater crowding and less ventila- 
tion in the domiciles during the cold than during the warm 
months, especially among the European peasantry. Dr. Smith 
says that in New York City, where the state of the domiciles is 
about the same the year round, the season appears to exert 
little influence on the prevalence of the disease. All author- 
ities agree that anti-hygienic conditions increase the liability 
to cerebro-spinal fever. It has prevailed extensively in bar- 
racks where soldiers were closely crowded together, and is very 
fatal among the poor in the New York tenement houses. Dr. 
Smith narrates many striking examples, which show that foul 
air and overcrowding increase not only the number, but the 
malignancy of cases. 

Some facts observed in certain epidemics would tend to show 
that the disease is mildly contagious. Hirsch is quoted as 
authority for the following example of its occasional con- 
tagiousness. A young man sickened with cerebro-spinal fever 
on February 8. The woman who nursed him returned to her 
home in a neighboring village, and there died of the same dis- 
ease on February 26. To her funeral mourners came from a 
neighboring township, and after their return home, three of 
them died with the same disease, one within twenty-four hours, 
another on March 4, and a third on the 7th. Smith relates 
a case of a boy who died of the disease on a Saturday or Sun- 
day, and whose mother was taken ill two days after washing 
his bed linen, as well as her young infant, both perishing from 
the same disease. It has been observed, however, that where 
multiple cases occur in a family, the disease begins at such 
irregular intervals in the different patients that there can be 
little doubt in most instances that it is not communicated from 
one to the other, but, like the fevers from marsh miasm, is pro- 
duced by exposure to the same morbific cause, existing outside 
the individuals, but within or around the premises. 

Numerous instances are cited in proof of this position. The 
strongest evidence of its non-contagiousness is afforded by the 
fact that a large majority of the cases occur singly in families, 
although no attempt is made to isolate the patients. In the 



CEREBROSPINAL FEVER. 607 

few cases which we have ourselves observed, there has been no 
extension of the disease to other members of the family, 
although there were other children of various ages having unre- 
stricted intercourse with the sick room. It is highly probable, 
therefore, judging from all the evidence pro and con, that the 
disease is only mildly contagious, if it be contagious at all, and 
if numerous cases in a family are affected, it is from the same 
original cause, acting upon all alike, rather than from direct 
contagion. The question has been discussed as to the possi- 
bility of the disease being communicated from animals to man- 
kind. No instances of the kind have been observed. During 
the epidemic which prevailed in New York in 1872, those who 
had charge of the infected horses, as the veterinary surgeons 
and stable men, did not contract the malady, at least no more 
frequently than others who were not so exposed. 

In some instances, an exciting cause of the disease seemed 
to be some depressing emotion or unusual excitement. It is 
probable that an individual exposed to the epidemic influence 
may have the disease precipitated by anything which suddenly 
lowers the vitality, whether it be protracted loss of sleep, absti- 
nence from food, mental taxation, fright, or unusual excitement 
of any kind. Such exciting causes as those just mentioned 
cannot obtain in all cases, for numerous instances have occurred 
in infants of three and four months of age, who are not pre- 
sumed to be subject to disturbances of this sort. When occur- 
ring as a primary disease, and its occurrence thus is the 
distinguishing feature between it and acute meningitis, it prob- 
ably affects susceptible infants and children who, in addition to 
susceptibility, are exposed to some malign influence, which 
affects the meninges by some power of election inherent in the 
poison itself or determined by some accidental circumstance, 
which either shocks or exhausts the nervous energies. While 
there are ample facts to justify the observations which 
have been made as to the epidemic tendency of the disease, it 
very often occurs sporadically. In this city (Chicago), while 
cerebro-spinal fever has been endemic for many years, there 
has at no time been what could be called an epidemic in any 
particular ward or section. The disease has affected widely 
separated individuals in different portions of the city, differing 
greatly in this respect from scarlet fever, measles and typhoid. 

Symptoms. — A typical case of cerebro-spinal fever, which 
recently occurred in our private practice, may here be cited as 
an example of its clinical history : 

Herbert G., eight years of age, a bright, healthy and well- 
developed lad, came home from school on the 19th of January 
last, at four o'clock in the afternoon, complaining of severe 



608 THE DISEASES OF CHILDREN. 

headache. He usually came home at half-past three, but this 
day he had been somewhat unruly, and the teacher had kept 
him for a half-hour by way of punishment. The misdemeanor 
was a slight one, but he had persisted in doing what he was 
told not to do. He made no complaint to the teacher of feeling 
ill. He had gone to school in the morning as vivacious and well as 
ever. He said nothing of feeling ill when he came home at noon 
for lunch. But when he came home at four o'clock, he com- 
plained bitterly of his head and his right ear. He laid down 
on the lounge, and at six o'clock, his supper hour, he tried to 
drink some milk, but immediately threw it up. An hour after 
he had a spasm, or rather a succession of spasms. 

I saw him a little before eight o'clock that same evening. 
The convulsions had then ceased. But he was unconscious 
and rigid. His head was drawn back, but there was no opis- 
thotonos. His arms were stretched out and rigid, as were also 
his legs. Both pupils were dilated, the left one much more 
than the right, and both were insensible to light and touch. 
The face was somewhat bloated and intensely red. His bron- 
chi Avere filled with frothy mucus, and his respirations were 
quick and accompanied with coarse, rattling rales. His pulse 
was rapid and full. As he could not be induced to swallow, he 
was given a hypodermic injection of ergotin, cold applications 
were applied to his head, and mustard leaves to the soles of his 
feet. These measures were continued at intervals for a couple 
of hours, when he died, without a recurrence of spasms or a 
return of consciousness. The duration of the attack lasted just 
six hours. Inquiry made at the school next day failed to 
elicit a single fact that shed any light on the case. He had his 
lessons and behaved just as usual, except for persistently stick- 
ing one foot out into the aisle, after being reprimanded by his 
teacher for so doing. He had received no injury from a fall or 
otherwise, and up to the time of his leaving school in the even- 
ing he seemed to have been in perfect health. He was an apt 
student and ambitious to learn. His teacher said that he was 
usually very obedient and tractable, but for a week or two prior 
to his sickness and death, she had noticed that he had spells of 
being somewhat sullen and a trifle willful. At home he was fond 
of showing off his acquirements, and was always lively and 
happy. He had never had previously any sickness of any 
magnitude. There were three other children in the house at 
the time of his death, all with unrestrained liberty, but none 
of them contracted the disease. 

This case is typical, in that it exhibited all of the peculiar 
features that distinguish this from the ordinary form of men- 
ingitis. Dr. Smith, from whom we have gathered much infor- 



CEREBROSPINAL FEVER. 609 

mation as to the history of the disease, and its symptoms in 
New York, says : " Cerebro-spinal fever rarely begins in the 
forenoon, after a night of quiet and sound sleep. . . . The 
commencement is usually without premonitory stage, and sud- 
den — unlike, therefore, the beginning of other forms of menin- 
gitis, which come on gradually, and are preceded by symptoms 
which, if rightly interpreted, direct attention to the cerebro- 
spinal system. . . . The ordinary mode of commencement 
is as follows: the patient is seized with vomiting, headache, 
and perhaps a chill or chilliness, so that there is a sudden 
change from perfect health to a state of serious sickness. . . . 
Children often have clonic convulsions, in place of the chill, or 
immediately after it, partial or general, slight or severe. Stupor 
more or less profound, or less frequently delirium, succeeds. 
In the gravest cases, semi-coma occurs within the first few 
hours, in which patients are with difficulty aroused, or profound 
coma, which, in spite of prompt and appropriate treatment, is 
speedily fatal. Those thus stricken down by the violent onset 
of the disease, if aroused to consciousness, complain of severe 
headache, with or without, or alternating with, equally severe 
neuralgic pains in some part of the trunk, or in one of the 
extremities. The pain frequently shifts from one part to 
another. Among the early symptoms of cerebro-spinal fever 
are those which pertain to the eye. The pupils are dilated or 
less frequently contracted, and they respond feebly or not at 
all, to light, if the attack be severe and dangerous ; often they 
oscillate, and occasionally one is larger than the other. Vomit- 
ing with little apparent nausea, and often projectile, is common 
in the commencement of cerebro-spinal fever. It occurred as 
an early symptom in fifty-one of fifty-six cases observed by 
Dr. Sanderson. In ninety-seven cases occurring in New York, 
most of them observed by myself, but a few of them related to 
me by the late Dr. John G. Sewall, vomiting occurred as an 
early symptom in sixty-eight cases. Its absence on the first 
day was recorded in only three cases, while in the remaining 
twenty-seven cases the records of the first day make no men- 
tion of its presence or absence. It was probably present in 
most of these twenty-seven cases as one of the first symptoms." 

Clonic convulsions are very common in the commencement 
of cerebro-spinal fever, but tonic muscular contraction and rigid- 
ity are still more so. This rigidity of the extremities is so con- 
stant a symptom in the disease, occurring even in cases which 
have been without spasms, that it has great diagnostic value. 
It sometimes lasts for days, or even weeks, before relaxation 
takes place. 

The mental state of those patients who are not rendered 
D. C— 39 



610 THE DISEASES OF CHILDREN. 

unconscious by the violence of the attack, is one of apathy or 
indifference. 

The intense headache, which is referred to the top of the 
head in some cases, and to the occiput or frontal region in 
others, is present in all cases. It is not only a prominent initial 
symptom, but it continues through the acute period of the 
malady. It shifts about from place to place, now on top and 
again in the back of the head and nucha. Pains are complained 
of in the epigastrium, in the umbilical and lumbar regions, 
along the spine, and in the extremities. In the head and along 
the spine it is most severe and persistent. In prolonged cases, 
the pain abates after the first few days, and by the close of the 
second week is much less pronounced than previously. Vertigo 
generally accompanies the headache, so that the patient reels 
in attempting to stand or walk. In protracted cases there is 
partial or complete loss of appetite, depending on the severity 
of the attack and its attendant pain, and more or less emacia^ 
tion ensues in consequence. Vomiting, which, as has been 
stated, is of common occurrence, may be an early symptom, 
and last but a few hours; or return at irregular intervals during 
the progress of the disease. It is like all vomiting in cerebral 
cases, without nausea and attended with little effort. 

The tongue is usually moist and but slightly furred. The 
sordes and brownish fur, which are so common in typhus and 
typhoid fever, are seldom or never seen in cerebro-spinal fever. 

In severe cases inability to swallow is an early and a promi- 
nent symptom. The pulse is generally more or less accelerated, 
and the heart's action is more rapid in proportion to the sever- 
ity of the attack. In exceptional cases, where there is com- 
pression of the brain, from an abundant exudation, there may 
be a pulse subnormal in rapidity. The temperature in this 
disease is subject to great and rapid fluctuations. In mild at- 
tacks it may not average above the normal, especially during 
the first few days, while in severe cases a higher temperature 
has been recorded than in any other disease. Fluctuations in 
the temperature occur not only from day to day, but at differ- 
ent hours of the same day. Smith mentions one case in which 
the thermometer registered 107 2-5° Fahr. This was in the 
commencement of an attack, the patient being two years old. 
Great and sudden variations of both pulse and temperature are 
characteristic of the disease, and have, therefore, considerable 
diagnostic value in obscure and doubtful cases. The skin is 
often the seat of papilliform elevations, the so-called goose 
flesh of the laity, and in cases where the temperature is reduced, 
there is a dusky mottling of the»cutaneous surface in severe or 
grave cases, which has given rise to the name "spotted fever," 



CEREBROSPINAL FEVER. 611 

by which it is sometimes known. In some epidemics there has 
been noticed a tendency to extravasations of blood under the 
cuticle, resembling bruises in appearance ; but this is seen only 
occasionally, and apparently never in Europe. 

The anatomical and pathological changes which occur in the 
course, and as a result of the disease, do not differ materially 
from those seen in other forms of meningitis, except that they 
are more general and less localized. In cases of great severity, 
the inflammatory exudation, fibrinous or purulent, or both, 
covers nearly, or quite, the entire surface of the brain. As to 
the nature of the malady and its differential diagnosis from 
kindred affections, Smith thus sums up his views : " The theory 
that cerebro-spinal fever is a form of typhus, once had its advo- 
cates, but it is now so generally discarded as untenable and 
absurd, that it would be a waste of time to consider the facts 
which differentiate the two maladies. Cerebro-spinal fever 
should, therefore, be considered as distinct from all other 
diseases, a malady sui generis, and in nosological writings it 
should be classified with those constitutional maladies which 
have specific causes." 

Duration. — The duration of cerebro-spinal fever is very vari- 
able. In some epidemics, and even in sporadic cases, the 
attacks are so intense that the system does not withstand the 
shock but a few hours. In other cases, seemingly mild at the 
commencement, the disease is subject to many exacerbations, 
and runs a very protracted course. Cases are recorded which 
lasted for one, two and three months. The after-effects in 
those which recover are often interminable. Smith records a 
case of a child three years of age who lost her speech on the 
second day of cerebro-spinal fever, and who was unable to 
articulate even the simplest word for two and a half months. 
Finally, she began to utter slowly and with difficulty, the easiest 
monosyllables, and after the lapse of more than a year, her 
speech was slow and lisping, her hands were tremulous and 
unsteady, she was easily fatigued, and cried often from over- 
sensitiveness. There are mild cases, however, of so indefinite 
a type as scarcely to be recognized, and many others whose 
duration is favorably terminated, either naturally or by treat- 
ment, in a few days or even hours. As has been truly said, 
"There is probably no disease which falsifies the predictions of 
the physician more frequently than cerebro-spinal fever." 
Grave initial symptoms are sometimes quickly dissipated, and 
do not relieve, while a mild onset not infrequently takes on a 
graver aspect, and terminates fatally -after a protracted siege, 
or a slow and tedious convalescence follows, after prolonged 
suffering. 



612 THE DISEASES GF CHILDREN. 

Diagnosis. — The diagnosis of cerebro-spinal fever from the 
other and more common forms of meningitis, is usually not dif- 
ficult. In the former, the onset is sudden, and the maximum 
intensity of symptoms is reached at a bound, or at least in the 
first few days ; while in the latter, there is a gradual and pro- 
gressive increase of symptoms from a comparatively mild com- 
mencement. Moreover, ordinary meningitis is generally a 
secondary affection, being due to tubercle, bronchitis, pneumo- 
nia, or other disease, and is, therefore, preceded and accom- 
panied by symptoms which are directly referable to the primary 
disease. Cerebro-spinal fever, on the other hand, begins 
abruptly in a state of previous good health. Again, in cerebro- 
spinal fever, after the second or third day, there is marked 
hyperesthesia, retraction of the head, and other characteristic 
symptoms, which are either not present or are less pronounced 
in ordinary meningitis. In the suddenness of its onset, and 
the nature and violence of its initial symptoms, cerebro-spinal 
fever is apt to be mistaken for scarlatina. But in the latter 
affection there is always more or less angina, and a few hours 
later the characteristic efflorescence appears on the skin. The 
peculiar fluctuations of pulse and temperature in cerebro-spinal 
fever will also aid in establishing the diagnosis. Scarlatina 
rarely, if ever, has the intense, almost unbearable, and shifting 
cephalalgia which is common to the other disease. 

Prognosis. — Cerebro-spinal fever is justly regarded as one of the 
most dangerous maladies of childhood. It is to be dreaded, not 
only on account of the great mortality which attends it, but 
also on account of its protracted course, the suffering which it 
causes, the possible permanent injury of the important organ 
which is principally involved, and the not infrequent irreparable 
damage which the eye and ear sustain. Under five years of age, 
the prognosis is more grave than when the disease attacks older 
children. At any age, an abrupt and violent commencement, pro- 
found stupor, convulsions, active delirium and great elevation of 
temperature, are symptoms which should excite solicitude and 
render the prognosis guarded. If the temperature remains above 
105° Fahr. for a considerable time, death is probable, even with 
moderate stupor. Numerous and large petechial eruptions show 
a profoundly altered state of the blood, and are, therefore, a 
bad prognostic, and so is albuminuria, since it shows great blood 
change, or nephritis, while other organs than the kidneys are 
probably also involved. 

A mild commencement, with general mildness of symptoms, 
as the ability to comprehend and answer questions, moderate 
pain and muscular rigidity, some appetite, moderate emaciation, 
little vomiting, etc., justify a favorable prognosis ; but even in 



CEREBROSPINAL FEVER. 613 

such cases it should be guarded till convalescence is fully- 
established. 

Treatment. — The treatment of cerebro-spinal fever must be 
palliative as well as medicinal. There is intense hyperemia of 
the brain and spinal cord, and our efforts must be directed to 
relieve this as speedily as possible, and subdue or diminish the 
inflammation. A hot mustard foot bath, or a general hot bath, 
in cases in which convulsions are present or threatening, is a 
useful measure, as it is calmative and acts as a derivative from 
the hyperemic nerve centers. Ice bags should be applied to 
the head and nucha, and maintained there as long as there is no 
chilliness produced, and there is some relief experienced from 
the intensity of pain. Cold may be applied also along the 
dorsal and lumbar vertebra, in severe cases, as well as to the 
head and neck. 

The sick room should be kept very quiet, and the number of 
attendants reduced to the minimum. All noises intensify the 
cephalalgia, and too many people about only aggravate the 
nervousness, which is already, in many cases, extreme. In the 
way of internal treatment, Dr. J. Lewis Smith recommends 
very highly the use of bromide of potassium. He says it has 
been proven by experiment that it causes contraction of the 
minute vessels of the nervous centers, so as to diminish the 
hyperemia, and at the same time it diminishes in a marked de- 
gree the reflex irritability of the spinal cord, two of the most 
beneficial and important effects of its use in this disease. 

In ordinary cases, not attended by eclampsia or symptoms 
which show that eclampsia is threatening, he gives four grains 
every two hours to a child of two years, and six grains to a child 
of five years. If eclampsia occurs, the bromide should be given 
more frequently, as every five or ten minutes, till it ceases. He 
gives the crude drug, dissolved in simple cold water. He states 
that he has rarely observed bromism in children who have re- 
ceived these doses, and never to the extent of doing any serious 
harm. This drug would seem to be quite homeopathic to 
cerebro-spinal fever, for a toxic dose of it produces exactly the 
symptoms we see exhibited in a typical case of this disease, 
viz., muscular weakness, dilated pupils, with, perhaps, impaired 
vision, unsteady gait, nausea or vomiting, and abdominal pains. 
It would be difficult to find a drug whose pathogenesis presents 
a clearer picture than this of the acute stage of cerebro-spinal 
fever. 

Ergot is another important remedy, whose action, however, 
is more physiological than homeopathic. It perhaps need not 
be excluded from our armamentaria on this account. Ergot 
has a remarkable power over the circulation, contracting the 



614 THE DISEASES OF CHILDREN. 

arterioles and diminishing the flow of arterial blood. It may be 
given in the fluid extract, tincture or wine of ergot. Where 
there is irritability of the stomach, or inability to swallow, it 
may be given conveniently in the form of ergotin, which is the 
alkaloid to which the beneficial effects of secale cornutum are 
due. This may be given hypodermically, dissolved in water 
with glycerin. 

The dose for a child two years old is ^V ^^ ^ grain. Of the 
fluid extract of ergot, the dose for an infant is one to three drops 
in water, equal parts. Gelsemmm in first dilution, is another 
valuable remedy, and so are aconite and belladonna. When 
eclampsia is present or threatening, cuprum must not be for- 
gotten, nor zinciim. Glonoin, from the intensity of its symp- 
toms, especially those of the brain, should make it a remedy of 
prime value. Besides these drugs, consult hyoscyamus, helle- 
bore, stramonium, opium, and veratriun viride. Great watch- 
fulness should be exercised during convalescence to prevent 
exacerbations. Study and all mental excitement should be 
strictly prohibited until some time after full recovery. As bad 
sanitary conditions are credited with being conducive of the 
disease, these must be remedied, and the patient provided with 
well-ventilated rooms, and given plenty of fresh air and food. 
When paralysis ensues, it must be treated the same as when 
occurring from other causes. 



CHAPTER II. 

INFANTILE TYPHOID FEVER. 

Synonyms. — Enteric Fever; Infantile Remittent Fever; 
TypJio-Malarial Fever ; Typlius Abdoniinalis ; Continued Fever. 

Definition. — According to the best authorities, the definition 
of typhoid fever is, an acute infectious disease, lasting from ten 
to twenty days, or longer, characterized by gastro-intestinal 
catarrh, febrile naovement of continued type, marked prostra- 
tion, rapid wasting, mild nervous symptoms, and, in a certain 
proportion of cases, a scanty and scattered eruption of rose- 
colored spots, which disappear on pressure and are developed 
in successive crops. 

But the folly of considering and treating disease by name, is 
nowhere better illustrated than in the fevers which are so com- 
mon in early life, the symptoms of which are in many cases 
totally unlike those ascribed to typhoid fever in adult life. 

A typical case of typhoid in the adult is almost unmistakable. 
No other disease runs a more regular course. The prodromal 
symptoms are very significant. The mental state is not like 
that of any other fever. The tenderness over the ileo-cecal re- 
gion is usually pronounced. The temperature curve alone is 
almost pathognomonic. From start to finish the disease is ac- 
companied with signs of fairly plain significance. But this is 
not the case with infantile typhoid. In early life — that is to 
say, under ten or twelve years of age — the disease does not ex- 
hibit those clearly defined symptoms that characterize it in 
after years. 

For example, a child is taken ill and has fever ; the fever re- 
mits in the morning, and increases at night ; there is anorexia, 
headache, nausea, nervousness, perhaps delirium ; the tongue 
becomes dry and furred down the center ; the bowels are at 
first constipated, then loose ; the fever continues day after day, 
with the same morning remission, the same evening exacerba- 
tion ; there is more or less meteorism, and the surface over the 
bowels is sensitive to the touch. But is this typhoid? 

There are no rose-colored spots ; no regular gradation of 
temperature ; no swelling of cervical glands, no symptoms of 
pneumonia, and there is no indication of scrofulosis or tuber- 
culosis. The only objective sign of unmistakable import is 

(615) 



616 THE DISEASES CF CHILDREN. 

persistent fever. This symptom continues with some modifica- 
tions and variations for days, or even weeks, until at last, after 
great loss of strength and flesh, we find a subnormal tem- 
perature, lasting for several days, a slow return of appetite, a 
gradual renewal of health and strength, and, after a tedious 
convalescence, the child is quite well again. 

But was this a case of typhoid fever? The difficulty has 
long been a puzzling one. It has led some German authorities 
• — Lebert among others — to adopt the term " infective ^^j/rzV 25," 
for febrile attacks of this kind. Certain English authors have 
attempted to bridge over the difficulty by employing the still 
looser expression, ''gastric fever ^ It may be repeated that 
typhoid fever, as seen in infancy and early childhood, does not 
present those clearly-defined symptoms which characterize the 
affection in adult life. Indeed, it holds so loosely to the type, 
that the landmarks are practically lost. The use of the term 
*' typhoid " under any circumstances, regardless of age, is a 
misnomer, and is open to serious objection. It presupposes 
that a more or less close relationship exists between it and 
typhus, when in reality no such relationship exists. The use 
of the term enteric fever in this connection is equally objection- 
able, for the very good reason, that in children there is no con- 
stant abdominal lesion attendant upon the disease, as there is in 
adults, and so we have, under the nomenclature, an enteric 
fever without any enteric involvement. 

Infantile remittent does not quite cover the requirements of 
the case, because all fevers of infancy are subject to remissions 
and exacerbations, and the use of the term is at best so indefi- 
nite that it is fast becoming obsolete. 

Retaining the term typhoid, however, we shall include under 
this head all of those fevers of childhood of an infectious 
nature and continued type, charging up this indefiniteness of 
characterization to the versatility and inaccuracy of the disease 
itself. Continued fever, unless due to subacute and protracted 
entero-colitis, is rare in infancy, but becomes more and more 
prevalent from five to six years of age upward. 

Etiology. — From what has just been said, it must be apparent 
that no one cause can obtain in all cases of the disease. Even 
in those cases which are unmistakably specific in character — 
with enteric involvement, typical temperature, rose-spots and 
bronchitis — the direct cause is in many cases doubtful. The 
disease, even in adults, is only mildly contagious, and then 
only through the medium of the evacuations. It is undoubt- 
edly spread by means of contaminated drinking water, milk 
and possibly ice. Among the causes which are worthy of men- 
tion in this connection are breathing impure air from sewers, 



INFANTILE TTPHOID FEVER. 617 

cesspools or cellars containing decaying vegetables. But 
these causes abound so frequently without producing typhoid 
fever that they must be regarded as predisposing rather than 
direct causes. Changing residence from country to city has 
frequently been noted as a conducing cause, age and other 
circumstances being also considered. To our mind, the anto- 
genetic origin of typhoid fever has never received the consider- 
ation which it is entitled to. Mention has already been made 
of the fact that certain German authorities speak of the disease 
as infective gastritis, meaning, as w^e take it, that the system is 
infected or poisoned by its own perverted secretions. When 
we consider the miles upon miles of lymphatic canals, and the 
infinite multitude of large and minute lymphatic glands, all of 
which are essential to the proper and orderly conduct of the 
machinery of life, and that their free and unembarrassed func- 
tion is absolutely necessary to carry away the products of de- 
composition and decay, as well as to furnish the material for 
the " renewal of life," it is doing no violence to logic or to the 
science of physiology to suppose that these living sewers, these 
vital emunctories, may become, under certain circumstances, 
carriers of filth and promoters of disease. 

What is true of typhoid is also and equally true of those 
pseudo-typhoids which are equally or even more common in 
early life, and for which no better appellation has been found 
than continued fever. In all cases the organism has become 
infected, either from within or from without, and the phenom- 
enon of fever is nature's method of disposing of the infection — 
a sort of cremation of morbid products and unworthy materials. 

Symptoms and Course, — The fever is, generally speaking, in- 
sidious in its onset, being rarely inaugurated by the chill 
which characterizes its commencement in the adult. Older 
children may experience chiUiness, or even a distinct rigor, but 
only in severe and exceptional cases. Headache and loss of 
appetite are among the early symptoms, perhaps accompanied 
with occasional vomiting. During the day there may be but 
few symptoms, and those of indefinite type, such as languor, 
dullness, or fretfulness, though symptoms of fever, with weak 
pulse and dry skin, are not wanting to careful observation. 
Towards evening the face becomes flushed, or a red, burning 
spot surmounts one cheek like a hectic glow% the headache is 
intensified, the lips become red, and the tongue dry. The 
child's sleep is restless and disturbed by mild delirium. As 
morning approaches the fever subsides, the sleep becomes 
more quiet and hopes are entertained of speedy recovery. 

Day after day the same history is repeated. The febrile 
movement becomes more pronounced as the disease progresses, 



618 THE DISEASES OF CHILDREN. 

the morning remission and the evening exacerbation continue, 
until after a time, the abdomen becomes tumid, the spleen 
is enlarged, diarrhea sets in, and the child becomes rapidly 
emaciated. Somewhere between the sixth and the twelfth day, 
in the majority of cases, the rose-colored eruption appears. In 
some cases, the number of spots is less than half a dozen. They 
are widely scattered over the abdomen, disappear on pressure, 
and reappear slowly when the pressure is removed. They ap- 
pear in successive crops, each crop remaining visible for two or 
three days. The headache, which is more or less prominent in 
the initial stage in the majority of cases, ceases as the disease 
becomes established. Epistaxis occurs occasionally during the 
first week, but is not abundant nor troublesome. A mild bron- 
chitis is nearly always present, with accelerated breathing, and 
more or less cough. This is usually not developed until the 
second week of the fever. Abdominal tenderness, especially 
on the right iliac region, is often present, but must not be mis- 
taken for the hyperesthesia which is common to all fevers in 
children, and which is observed especially over the abdomen, 
chest and inner portions of the thighs. 

The temperature in infantile typhoid is subject to great and 
singular variations. The remissions often present no regularity 
from day to day in the time of their occurrence. If the tem- 
perature be taken every two or three hours, it will show a 
remarkable irregularity, sometimes running up and down several 
times in the course of twenty-four hours. The acme may be 
reached at any hour, but there is a tendency to the occurrence 
of two distinct exacerbations, one at about four o'clock, and 
the other at nine o'clock P. M. But there is no stated regular- 
ity about it. The pulse is apt to follow the temperature quite 
closely in its rise and fall, but exceptions to this rule are nu- 
merous. It is not uncommon in this disease to have a tempera- 
ture of 103° Fahr., or even higher, and a pulse considerably 
under 120. 

On the other hand, the pulse may be as rapid as 150 or more, 
and recovery take place. In some cases, the rhythm and the 
force of the pulse is much disturbed, and may even be dicrotic, 
but a dicrotic pulse in childhood is much more rare than in adult 
life. Diffuse bronchitis and broncho-pneumonia occur as com- 
plications in a certain proportion of cases. In the majority of 
instances, the bronchitis is of moderate intensity, and ceases as 
soon as the fever has spent its force. 

Hypostatic congestion, due to position and feeble circulation, 
is by no means uncommon. It is usually limited to the pos- 
terior portions of the chest and the bases of the lungs. 

Symptoms indicative of disturbance of the digestive organs 



INFANTILE TYPHOID FEVER. 619 

are practically the same as in adults. There is generally but 
little desire for food during the progress of the fever, and thirst 
is easily satisfied. When convalescence begins, however, the 
appetite is ravenous and dif^cult to control. As a rule, the 
tongue is red at the edges and tip, and is covered in the center 
with a pasty, yellowish-white fur, which in the course of the 
•disease gives way to a smooth, bright-red and varnished look. 
Sordes on the teeth and gums are not common in childhood. 
The lips are apt to become cracked and fissured, and covered 
with superficial crusts. Aphthous ulcerations also occur on the 
tongue and at the corners of the mouth. The condition of the 
bowels is extremely variable. In the commencement of the 
attack constipation is the rule. In its later course there is a 
marked tendency to diarrhea, the number of passages varying 
from two or three to ten or more in the twenty-four hours. 
The stools are apt to show the well-known appearance of thick 
pea-soup, and divide, upon standing, into an upper, cloudy, quite 
liquid layer, and a lower stratum composed of greenish-yellow 
masses. Except in the case of very young infants, the evacu- 
ations are under the control of the will. In very severe and 
critical cases only do they become involuntary. 

Intestinal hemorrhage is rare in infancy and childhood, al- 
though in exceptional cases it does occur. The late Dr. Earle, 
of this city, had a case of fatal hemorrhage in an infant twenty- 
two months old. Post-mortem examination revealed the char- 
acteristic lesions of enteric fever. The spleen is very generally 
enlarged, although probably not more so, and no more fre- 
quently than in other acute infectious diseases. In cases in 
which the fever runs unusually high, the spleen is apt to be in- 
volved early in the course of the disease ; but pain over the 
spleen is rare, and the enlargement of this organ begins to sub- 
side with defervescence. It has been noticed in cases of relapse 
that the spleen continues enlarged during the interval between 
the primary attack and the relapse. 

The nervous symptoms in infantile typhoid fever are not so 
pronounced as is the case with adults. Headache is common 
as a prodromal symptom, and is so especially at night, dur- 
ing the first week of the disease. The delirium is generally 
moderate and mild, and confined generally to the night-time, 
and is sometimes associated with night terrors. It is transient 
and recurrent, rather than continuous, and of the type known 
as wandering delirium. In very young infants delirium is apt 
to be replaced by sudden, sharp and prolonged outcries. In 
older children we have the same character of delirium as in 
adults. Twitching of the muscles of the face and hands — the 
so-called subsultus tendinum — is common, but plucking at the 



620 THE DISEASES OF CHILDREN. 

bedclothes, even in the worst cases, is rare in children. Enteric 
fever differs from scarlatina in the extremely rare occurrence 
of acute nephritis as a sequel. It is said that menstruation in 
girls at puberty is apt to be profuse and prolonged. In some 
cases, however, it is very scanty, or postponed until conva- 
lescence is fully established. Enteric fever does not, during its 
course, confer any immunity from the ordinary diseases of 
childhood. If anything, the reverse is true. Instances are re- 
corded wherein measles and scarlatina have either preceded or 
followed the disease, or have co-existed — the eruptions merging 
the one into the other. 

Duration. — The duration of enteric fever in childhood is very 
variable. Many cases last only ten or twelve days, while others 
last twice as long. It is probable that in many instances the 
fever has been in progress for several days before attention has 
been attracted to it. In some cases doubtless the primary 
fever is overlooked altogether, and the physician is called only 
at the time of relapse. 

Diagnosis. — If we attempt to discriminate between true 
typhoid fever, as it occurs in infancy, and that other form 
which is much more common, and in which there is no evidence 
during life of any enteric lesion — the simple continued fever 
of some authors — we shall have to be very exact in our obser- 
vations and very expert in our examinations. It is much easier 
to exclude such diseases as the eruptive fevers, malarial fevers 
and acute tuberculosis. The latter especially presents many 
symptoms that might lead to confusion. The insidious onset 
is the same in both diseases, and the temperature is subject to 
the same oscillations ; vomiting is often seen in the early stage 
of typhoid, as well as in tuberculosis, and in the latter affection 
diarrhea is by no means uncommon. Only careful observation 
continued for quite a period of time will suffice to distinguish 
one from the other. It is sometimes a very difficult matter to 
distinguish typhoid from meningitis. The frontal headache is 
common to each, so are muscular tremors, and in meningitis of 
tubercular origin there maybe pleurisy, bronchitis or even some 
evidence of local consolidation. In the latter disease, however, 
there is likely to be intolerance of light, and the temperature 
is not usually as high as in typhoid fever. Sub-acute enteritis 
or entero-colitis has many features that simulate typhoid, but 
in the latter there is bronchitis and cough, while in the inflam- 
mation these are wanting. There is absent also the headache, 
epistaxis and delirium ; nor are there any rose spots. Should 
there be, or have been, other cases of typhoid fever in the 
house or family, this fact would miaterially aid in clearing up 
the diagnosis. 



INFANTILE TTPHOID FEVER. 621 

Treatment. — A case of fever, such as we have been consider- 
ing, may be of all grades of severity. As we have seen, many 
cases are atypical. In some the bowels are slightly or seriously 
implicated ; in others, not at all. It would be manifestly ab- 
surd, under such circumstances, to treat all cases alike, or to 
expect that any one remedy can be of universal efficacy, either 
to abort the fever or modify its course. There is no such 
remedy known. Each case must be individualized and treated 
symptomatically. Sometimes a single symptom may stand 
out with such prominence as to point to the appropriate drug, 
but more often the totality of the symptoms will afford a better 
guide. 

The fact must not be forgotton that water is the great anti- 
pyretic. By its judicious use the intensity of the fever can be 
materially abated, and when the nervous symptoms are promi- 
nent, water is wonderfully tranquilizing. We have no words 
but those of censure for that heroic hydropathy that plunges a 
fever patient into a bath of 6Z^ Fahr. or lower, and repeats the 
shock every two or three hours. Such a procedure is danger- 
ous in the extreme. But the entire body may be sponged over 
with tepid water, or water and alcohol, once a day, or oftener 
if the temperature runs high, and with excellent results. 

Where defervescence is tardy, and the skin is devoid of per- 
spiration, the wet-sheet pack, given as directed in our intro- 
ductory chapter, will be preferable to the sponge bath. 

The diet of these patients is of the greatest importance. 
Where fresh milk is used, it should be boiled and strained, 
and then may be given either cold or hot, whichever is pre- 
ferred. 

Where the stomach is irritable, or milk does not agree, 
koumiss or buttermilk may be substituted. Barley water, or 
weak mutton broth, is permissible with older children, but beef 
tea and chicken broth are not suitable for any cases. Starchy 
foods should be avoided, for the secreting powers of the sali- 
vary glands and also the pancreas are often seriously impaired. 
During convalescence great care must be exercised lest the 
weakened digestive organs be overtaxed. At this time the 
food should consist of easily digested articles, such as bread 
and butter, light puddings, custard and meat broths ; but solid 
food ought not to be eaten until the temperature has been 
normal for a week or more. 

Internal Treatment — Arsenicum. — Probably this remedy is 
called for in a greater number of cases than any other. The 
more serious the case, speaking in a general way, the more ap- 
propriate is its selection. It may not be needed, as Prof. Kip- 
pax remarks, in the early stage of the fever ; but sooner or later 



622 THE DISEASES OF CHILDREN. 

its symptomatology will indicate that it covers a larger field of 
symptoms than any other one drug. 

Dr. Thomas Nichol says of arsenicum : " In the most dis- 
heartening cases, cases which seem to be utterly hopeless, when 
the vital functions are in the grasp of a morbid poison of the 
most malignant kind, and the very life-blood is profoundly and 
completely altered, tJie7i, this great remedy is capable of saving 
life." 

It is rarely indicated when both body and mind are tranquil, 
for restlessness, with anxiety, is one of its most prominent key- 
notes. 

In the arsenicum typhoid case, the heat of the skin is dry and 
burning ; the patient calls for water often, but drinks little at a 
time ; the head throbs violently with pain ; desire to throw off 
the bed covering \ great restlessness. The pulse is small and weak, 
or possibly irregular and intermittent ; exhaustion both of body 
and mind. Even early in the progress of the disease there are 
evidences of decomposition of the fluids of the body ; the odor 
of the stools is very foul and there is a fetid odor to the patient's 
breath ; the nosebleed is ichorous. Delirium is attended with 
tremulousness, and at night is often violent. The features are 
greatly changed ; there is a pale, yellow, cachectic look, often 
livid or lead-colored. The eyes are dull, glazed and sunken ; 
the lips dry and fissured. The stomach is tender to external 
pressure ; spleen is swollen and painful ; there is marked swell- 
ing and distension of the abdomen. There are sounds of mov- 
ing flatus and liquids in the intestines. Deafness, with ringing 
in the ears and head. The evacuations are exhaustive ; stools 
watery, small and yellowish, or greenish-brown and acrid. The 
urine is scanty and turbid ; rapid emaciation ; edematous swell- 
ing of the feet ; circumscribed redness of one or both cheeks ; 
involuntary urination ; very tenacious mucus in the chest (tartar 
emetic, kali bich^ ; extensive pulmonary hypostasis, symptoms 
worse from i to 3 A. M. 

Acid Nitricuvi. — This remedy is chiefly indicated in the ad- 
vanced stage, where the abdominal lesion has become pro- 
nounced ; marked tenderness of the abdomen, especially in the 
ileo-cecal region ; gurgling on pressure, with blood-streaked 
diarrheic stools, which are foul-smelling, brownish, pasty or 
slimy. The tongue is smooth, glossy and deep red. The men- 
tal stage is irritable and excitable. Pulse irregular, and inter- 
mits QWQxy fourth beat (third beat muriatic acid). Emaciation, 
especially of the arms and thighs. (Kippax.) 

Acid Miiriaticum. — Hughes ranks this remedy with arseni- 
cum as one of the remedies against the essential lesion of ty- 
phoid. It is the great remedy, not only when putridity 



INFANTILE TTPHOID FEVER. 623 

threatens to set in, but also when it is fully developed. The 
stools are frequent, foul and scanty, often blood-streaked, and 
the discharges are mingled with shreds of intestinal mucous 
membrane, and fragments of whitish mucus. The patient is 
extremely weak. The patient is constantly settling down in 
bed ; stupor, with perfect indifference to surrounding events. 
The abdomen is swollen and tender, and the sphincter ani is 
partially paralyzed. The breath is very offensive, and the mu- 
cous membrane of the mouth is ulcerated in patches (stoma- 
titis). Delirium continues. Glistening eyes, contracted pupils ; 
hypersensitiveness to sounds. Excessive dryness of lips, mouth 
and tongue. Profuse discharge of clear, acid urine. Pulse 
rapid and feeble, intermits every third beat. Respiration ac- 
celerated. 

Baptisia. — The time is not far away since baptisia was re- 
garded by the great majority of homeopathic physicians as 
the sheet anchor — the sine qua non — for the successful treat- 
ment of typhoid fever. The remedy has become indissolubly 
linked with the disease, but the claims which were once made 
for its curative powers have been much modified by clinical 
experience. It is undoubtedly the remedy par excellence dur- 
ing the first week. After that, if the disease is not aborted, 
there are other drugs possessing far more efficacy. Dr. Kippax 
says, speaking of baptisia : ** It is capable of exciting a fever 
resembling that of typhoid, and of producing congestion and 
catarrhal inflammation of the intestinal mucous membrane, 
with abdominal tenderness and diarrhea, the pathological con- 
dition present during this period," the first week. 

Other remedies, however, besides baptisia, are capable of 
doing the same thing, and it is only by noting the minutest 
shades of difference, that we can properly affiliate the drug to 
the disease. The baptisia patient feels chilly all day, and hot 
at night ; chilliness and soreness of the whole body, with intol- 
erance of pressure on lying. The pulse is full, soft and quick. 
The tongue is dry and red, swollen and thick. The stools are 
very fetid, and so is the patient's breath. Indeed, /^'//^^'//'j/ is 
one of the prime characteristics of this drug. The mental state 
of the baptisia patient is another peculiarity that will serve to 
distinguish it from its congeners. 

There is great nervous restlessness ; heavy sleep with fright- 
ful dreams, or *' the patient cannot go to sleep because she can- 
not get herself together ; her head feels as if scattered about, 
and she tosses about the bed to get the pieces together," or 
'* feeling as if the lower limbs were severed from the body ; 
sensation as of a second self alongside in bed " {bell.). Falls 
asleep in the midst of attempted conversation. Confusion of 



624 THE DISEASES OF CHILDREN. 

ideas. The mental state and fetidity of all the secretions are 
the marked characteristics of baptisia. 

Bryonia. — This remedy is also chiefly indicated in the early 
stages. It is especially valuable when bronchitis or pulmonary 
congestion complicates the fever. The bryonia patient is 
exceedingly irritable, and easy to take offense. Violent, op- 
pressive, stupefying headache. Feels better from lying down ; 
wants to go home. Buzzing in the ears, with hardness of 
hearing. Face red, hot and puffy. Excessive thirst for large 
quantities of w^ater. Dark, almost brown, urine. Bleeding 
from the nose after rising or during sleep. The tongue is at 
first white or yellowish, but soon becomes dry, rough and dark 
in color. Cannot sit up from nausea and dizziness. Dry, 
hacking cough, with stitches in the region of the chest and 
liver. Pain in the back and limbs when moving. Epigastric 
region painful to touch and pressure. 

Patient is obliged to lie perfectly quiet, because the slightest 
motion causes nausea ; vomiting with nausea on waking in the 
morning. At the commencement of the fever chilliness and 
heat alternate, but later on the heat is intense and almost con- 
tinuous. Dr. Nichols, discussing the dubious question of the 
possibility of aborting typhoid fever, quotes Dr. Fornils, of 
Philadelphia, as saying : " ' I think that if any abortive power 
can be ascribed to any drug here, bryonia has it ; its success 
will depend on its early application, a thing not always possi- 
ble, as we are generally called too late. I am not an enthusiast, 
but I have seen this drug work marvels, subduing the gastric 
irritation, cleansing and moistening the tongue, healing the 
cracks, and enabling the stomach to retain liquid food, dimin- 
ishing and changing the color of the stools, and finally bringing 
the whole condition to a favorable turn.' " Nichols, for himself, 
says : " Formerly I believed that no remedy could materially 
change or shorten this disease, but now I am of the opinion 
that the homeopathically indicated remedy can change the type 
of fever from the normal to the mild or abortive ; but in order 
to effect this, you must begin treatment early, that is, before 
the disease is developed. And then you can never be quite 
certain that it was typhoid fever you have been treating, for in 
mild or abortive cases, the pathognomonic symptoms are ab- 
sent. In my experience this abortifacient power has chiefly 
been exercised by bryonia and baptisia." My own experience 
is in accordance with these views, qualified by the remark that 
typhoid is probably much more amenable to drug treatment in 
early than in mature life. While the producing cause has virgin 
soil to work upon, so has the indicated remedy ; and when 
taken in time, that is to say, before the disease has had time to 



INFANTILE TTPHOID FEVER. 625 

-complicate itself, we are able to prevent the development 
of those special symptoms which are characteristic of the 
affection in mature years. May this not be the reason why 
we often lack, in infantile cases, those distinctive signs of 
typhoid, nature, unaided, being sometimes able to partially 
or wholly prevent the full development of the typhoid 
symptoms ? 

RJius toxicodendron. — The symptoms which Indicate rhus are 
somewhat analogous to those of bryonia, but the patient is from 
the commencement more seriously ill. In the bryonia case 
there is but little tendency to putridity of the fluids of the 
body, while in rhus patients this is very marked. When rhus 
is called for, the patient lies stupid and semi-comatose — so weak 
that when conscious he is unable to move. Watery diarrhea, 
often involuntary ; thin, watery epistaxis ; violent cough with 
shortness of breath ; pain in the throat, as if the tonsils were 
swollen ; slight perspiration over the whole body towards morn- 
ing ; bruised feeling over the whole body, with soreness in all 
the bones; constant desire to lie down and be quiet. The lips 
are dry and bleeding, and the tongue is swollen, dry, and brown. 
The red, triangular tip is very characteristic. Great thirst for 
cold drinks, especially cold milk. Pale, sunken face, with dark 
rings around the eyes. Sordes on teeth and gums. Baehr 
says: ''Cases adapted to rhus never run a speedy course, nor 
will the crisis have to be expected previous to the seventeenth 
day ; until then the medicine will have to be continued without 
fear, unless some other remedy should be indicated by particu- 
lar symptoms." 

Belladonna. — This remedy is indicated in cases wherein there 
is great cerebral congestion. The pain in the head is exces- 
sive ; there is vertigo, with staggering on attempting to walk. 
The headache is aggravated by noise, shocks, motion, or when 
moving the eyes. The carotids, and, indeed, all of the cere- 
bral arteries, beat and throb more markedly than normal ; 
the patient is sleepless, but greatly desires sleep ; frightful vi- 
sions are seen as soon as the eyes are closed; sighing during 
sleep; sudden awakening with a start and fright; tendency 
to bury the head in the pillow and draw up the legs. The 
pulse is hard, small and rapid ; face and hands cold ; stertor- 
ous respiration; subsultus tendinum ; tendency to coma. 
The delirium is furious. Visions and delirious talk of dogs, 
wolves, mice, giants and fire. The child does not know his 
nearest friends. The diarrhea is watery, profuse and painless. 
Perspiration. 

Phosphorus. — This remedy is indicated in cases of adynamic 
type and where there is a complication of bronchitis and pneu- 
D. C— 40 



626 THE DISEASES OF CHILDREN. 

monia. The stools are painless, profuse and either resemble 
dirty water or are black, like coffee dregs. 

Constant sleepiness : contracted pupils ; coma vigil ; dullness 
of hearing ; hard, dry cough ; regurgitation of food ; loud rum- 
bling in the bowels. Typhoid pneumonia. — Hepatization of the 
lungs ; great emaciation ; epistaxis ; involuntary stools ; meteor- 
istic distension of the abdomen, with rumbling and gurgling; 
profuse night and morning sweats ; burning in stomach ; low, 
muttering delirium ; small, quick, easily compressed pulse ; 
regurgitation of food in mouthfuls ; diarrhea, aggravated by eat- 
ing ; feeling of fullness and distension in stomach, even after 
eating a very little. 

Other remedies which should be consulted in cases of this 
kind are : argaricus muse, apis mel, arum triph., calcarea 
card. J camphor, car bo veg., cmchona, colchicum, gelsemium, hyos- 
cyamus, hamamelis, ignatia, lycopodium, mercurius, nux mos- 
chata, 7111X vomica, opium, Pulsatilla, silicia, sulphur, sulphuric 
acid, tartar emetic, terebinthiiia, veratrum alb., veratrum, viride, 
zincutn. 

The treatment during convalescence is all important. It 
will not do to consider the patient as well as soon as the fever 
has abated. A subnormal temperature nearly always succeeds 
the period of pyrexia, and in the early morning the thermome- 
ter may not register above 96° or 97° Fahr. The vitality is at 
low ebb and the greatest care is necessary in the matters of 
eating, drinking and exercising. In cases where there is great 
prostration, or in which the convalescence is protracted from 
weakness, alcoholic stimulants are permissible and useful, espe- 
cially so when the heart's action is feeble or irregular. Wine- 
whey, in very small quantities, regulated according to the age 
of the child, may be given at intervals of two or three hours. 
It is prepared by adding four ounces of sherry wine to eight 
ounces of boiling milk, and then straining after coagulation. 
In sudden emergencies, a little whisky toddy may be given, 
i. e., a tablespoonful of whisky to four of hot water, to which 
a little loaf sugar is added. Vin Mariani (cocoa wine), is an 
admirable wine for convalescents, and may be given in very 
small doses to quite young infants. 

We do not like the California wines for invalids and chil- 
dren. They are too heady, too alcoholic, and do not set well 
on the stomach. Probably the best wine in the world for the 
purpose here indicated, is Lorenz Reich's Hungarian Tokay 
(Tokayer Ausbruch). It is imported direct by Mr. Lorenz 
Reich, of New York City, especially for medicinal purposes, 
and is a smooth, rich and well-aged Tokay, of absolute purity, 
neither acid nor oversweet. No other wine, imported or 



INFANTILE TYPHOID FEVER. 627 

domestic, has received such unqualified endorsement from 
the highest professional authorities of all schools of medical 
practice. 

Children recovering from a continued fever, should not 
be sent to school until their health and strength are fully re- 
stored, which may be weeks, or in some cases months, after 
all fever has ceased. A sojourn in the country, for city-reared 
children, has a very salutary effect in promoting a restoration 
to health. 



CHAPTER III. 

INTERMITTENT FEVER (MALARIAL FEVER; CHILLS AND 
FEVER ; MIASMATIC FEVER ; AGUE). 

Definition. — Intermittent fever is an endemic, sometimes 
epidemic, paroxysmal disease, each paroxysm consisting of 
a succession of definite stages, viz., a cold, a hot and a sweat- 
ing stage. The paroxysms are separated from each other by 
intermissions or apyrexial periods of varying length, during 
which the patient enjoys comparative health. According to 
the length of the intervals, the fever may be of different types, 
as the quotidian, the tertian and the quartan. There are also, 
double forms, as double quotidian, double tertian, etc. 

Etiology. — Intermittent fever is due to malarial poisoning. 
Its miasmatic origin is universally conceded. The term malaria 
is a compound of two Italian words, inali, meaning evil, or 
harmful, and aria, air, and has come to signify the hurtful and 
disease-producing emanations from marshes or decaying vege- 
tation. The exact nature of the poison or miasm is unknown. 
Certain requirements or factors are necessary to the develop- 
ment of the morbific agent. These are, rank vegetation, 
moisture and a certain average degree of temperature. Unless 
all three of these factors are operative conjointly, the poison 
will not materialize. The average daily temperature must not 
fall below 58° Fahr. ; there must be an abundance of vegetation, 
and a due amount of moisture. 

Malaria may enter the human system either by the respired 
air, or through the digestive tract, with food or drink. After 
it has once entered the organism, the period of its incubation 
varies from a few hours to weeks or months. Cases are on rec- 
ord in which a whole year has elapsed between the inhibition 
of the poison and its morbific manifestations. Other instances 
have been noted where a chill has been experienced within 
twenty-four hours after sleeping in a malarious locality. No 
race or nationality enjoys complete immunity from its effects ; 
the blacks are, however, less susceptible to it than the whites. 

All periods of life, also, from infancy to old age, are suscep- 
tible. The greatest susceptibility is exhibited between the 
ages of five and fifteen years. The weak and the debilitated are 
more subject to its influence than the robust. An organism 
(628) 



INTERMITTENT FEVER. 629 

once invaded by its pernicious influence is thereby rendered 
more liable to subsequent attacks. A careful study of the 
physical conditions favorable to the development of malaria 
shows that it is most prevalent about marshes, swamp lands and 
damp bottom lands. If the low lands are saturated with salt 
water and subject to an occasional overflow of fresh water, the 
conditions for the evolution of malaria are exceptionally favor- 
able. 

Cutting off timber from new lands and exposing the damp 
and half-decayed vegetation beneath, to the rays of the sun, is 
a very prolific source of malaria. The excavations in the sub- 
urbs about Chicago, made necessary by the laying out of new 
streets, building sewers, placing cable tracks, making cellars, 
etc., etc., are at the present time giving rise to malarial diseases 
along the line of these improvements. Personally considered, 
other things being equal, all weakening influences, such as in- 
creased moisture of the atmosphere, exposure to excessive 
solar heat, sudden cooling of the cutaneous surface, and inordi- 
nate eating and drinking, favor the action of the malarious 
influence. These, each and all, act by disturbing the equi- 
librium of the body, and thus lowering the power of resistance. 

There are other conditions, fortunately, which are inimical 
to the production of malaria, among which may be mentioned 
the extremes of latitude. Malaria is seldom generated north 
of 63° north latitude or south of 57° south latitude. The 
further we recede from the equator within these limits, the 
more feeble becomes the malarial poison. Again, malaria is 
seldom found beyond 1,000 feet above sea level ; an average 
temperature below 60° Fahr. is always and everywhere unfavor- 
able to the generation of malarial poison. The daytime is less 
favorable for the development of the miasm than is the night. 

It is said that strong winds diminish the virulence of the 
poison, doubtless because they scatter it broadcast, and thus 
prevent its concentrated influence. A hot and dry atmosphere, 
with little or no wind, especially after heavy rains, increases it. 

It has been found by experience that certain plants, such as 
the sunflower (Helianthus Annus), the calamus (Acorus Cala- 
mus), and the eucalyptus, have the power of absorbing the 
miasm, and have been used with much success in malarious 
districts. 

From time immemorial malarial fevers have been observed to 
show a tendency to ameliorate or terminate on certain days, 
which have been for this reason denominated " critical." This 
tendency has been variously explained, but the explanations 
are, for the most part, more fanciful than philosophical. Clin- 
ical experience, however, endorses the statement that the fever 



630 THE DISEASES OF CHILDREN. 

is more apt to terminate on certain days than others. The 
critical days are as follows : the third, fifth, seventh, ninth, 
eleventh, fourteenth, seventeenth, twenty-first, twenty-seventh 
and thirty-first. The non-critical are the intermediate days ; 
but the fourth and sixth are considered secondarily critical. 
Cases that pass the seventh day are apt to run on to the 
eleventh ; and those which pass the fourteenth are apt to go to 
the twenty-first. 

Symptoms and Course. — The clinical history of a case of in- 
termittent fever, which is the commonest form of malarial poi- 
soning, is about as follows : The prodromal or incubative stage, 
if present, is of variable length and is attended by indefinite 
symptoms, or none at all. Some patients experience a sensa- 
tion of languor, accompanied by a tired feeling, with frontal 
headache, yawning, stretching and general malaise. The tongue 
is somewhat furred ; the appetite is impaired or lost ; there is 
a metallic taste in the mouth, the breath is foul and the skin 
takes on a dirty-yellow or icteric hue ; the urine is scanty and 
high-colored ; the fecal discharges are dark-colored and offen- 
sive. After these symptoms, or some of them, have continued 
for a variable period, they eventuate in a distinct rigor usually, 
which is the commencement of that series of phenomena which 
characterize the paroxysmal stage. This stage is, in a typical 
case, marked by three distinct divisions: first, the chill; second, 
the fever ; third, the sweat. 

When the attack presents itself every day, it is called quotid- 
ian ; every other day, tertian ; every fourth day, quartan. In 
double quotidian, there are two chills daily — one in the morning 
and one in the evening. In double quartan, there is an attack 
on two successive days and one day without an attack ; in 
double tertian one chill daily, but the time of chill alternates 
every other day. In children the quotidian form is most com- 
mon. Bohn gives the relative frequency of the three forms as 
3:2: I, although this varies according to the nature of the epi- 
demic. 

As a rule, to which there are apt to be exceptions, the attack 
comes on between ten o'clock in the morning and one in the 
afternoon. There are two forms of intermittent fever and of 
very different gravity — the pernicious and the mild form. 

The first or pernicious form., is not uncommon in infancy and 
childhood, and is generally ushered in with a convulsion instead 
of a chill. The child may be attacked in the midst of perfect 
health, or may be for a short time restless and feverish. Yawn- 
ing and stretching are among the more noticeable prodromata. 
There is sometimes vomiting or one or more loose evacuations 
just preceding an attack. Quite as often, in this pernicious 



INTERMITTENT FEVER. 631 

variety, the first evidence of illness, is a turning of the face a 
pale or bluish-pale color, and very shortly the child has a con- 
vulsion or falls into a comatose state, from which it never ral- 
lies, remaining in this condition for one, two or more days and 
finally dying from asthenia, edema of the brain, or some other 
complication. If the first attack does not prove fatal, the con- 
vulsions gradually diminish in intensity and number, the ex- 
tremities grow warmer, the bluish color and the pallor disappear, 
and the temperature begins to fall. After a time the child 
resumes consciousness, and soon is apparently quite well again. 
But the next day or the day after the attack is renewed, and 
this second paroxysm may end fatally The temperature, if 
taken during a paroxysm and in the rectum, is very high (104° 
or even 108° Fahr.). The pupils are contracted, or one may be 
contracted and the other dilated. The child may be comatose 
from the beginning, or the convulsions may precede the coma. 

When the attack comes on thus suddenly, in a previously 
healthy subject, the diagnosis is sometimes very difficult to 
make. The resemblance to cerebro-spinal fever is exceedingly 
close. The character of the locality and the known presence of 
the miasm may be the only clue to the real nature of the seiz- 
ure. 

It is very rare indeed for these pernicious cases to terminate 
otherwise than fatally. In the benign form of intermittent 
fever, the attendant phenomena vary with age. In young in- 
fants we rarely have a complete attack — that is, a complete 
sequence of stages. It is asserted by some, that infants do 
have the chill, fever and sweat, the same as adults; but this is 
surely exceptional. More often one of the links is missing, and 
usually this is the chill, a convulsion frequently taking its 
place, the other stages, fever and sweat, following in their 
regular order. Infants who do not have a distinct rigor, may 
have symptoms which very nearly approach a chill, viz.: cold- 
ness of the nose and extremities ; blueness of the lips ; dark 
circles about the eyes, and a look of great exhaustion. If the 
child has just eaten, there is apt to be vomiting, or at least 
nausea. If convulsions take the place of the chill, as just des- 
cribed, they are not likely to be much prolonged — rarely last- 
ing more than a few hours — when the next stage, that of fever, 
ensues. During the chill or convulsions, the temperature 
rapidly rises to 103° or higher, and remains there until the 
paroxysm is over, when it gradually diminishes, until, after the 
lapse of several hours, it reaches a normal or subnormal degree. 
The sweat that follows is profuse and exhausting, yet, strange 
to say, no sooner is it over than the appetite returns, the face 
brightens up and the child seems quite well again. After a 



632 THE DISEASES OF CHILDREN. 

succession of attacks, however, the cachexia begins to manifest 
itself ; the complexion loses its natural color, and is pale or 
jaundiced. The patients now become listless and lose their 
appetites. The spleen becomes enlarged, either temporarily 
or permanently, and may usually be felt by careful palpation 
through the abdominal walls. With older children, who are 
able to describe their sensations, the symptoms do not differ 
essentially from those seen in adults, especially in typical cases. 
But children are more prone than adults to suffer from the 
cachexia, and then we have all manner of symptoms and com- 
binations of symptoms, which are oftentimes exceedingly 
puzzling. 

It would be impossible to ^\yi^ even a 7'L'snine of the various 
phases which the malarial cachexia may assume under varying^ 
circumstances. In some cases the chill is absent, and the other 
stages are manifested in a partial or fragmentary form. In 
these cases there is more or less fever, followed by a sweat, and 
the periodicity may be regular or irregular. The popular name 
for such an attack is " dumb ague." 

Oftentimes the chill and the fever are replaced by an intense 
neuralgia, appearing daily about the same hour, or perhaps 
every other day. In young children masked interniittents of 
this kind, are apt to take the form of diarrhea, dysentery or 
dyspepsia. But there is no disturbance of function nor disease 
of any organ or tissue, but may be influenced by the malarial 
poison, and take on a periodicity unknown to similar com- 
plaints outside of malarious localities, or at least unknown to 
those who have not been exposed to miasmatic influences. 

Diagnosis. — It is only in masked cases, which have the 
cachexia, but not the regular paroxysms, that there can be any 
difficulty about the diagnosis. In such cases there is pretty 
sure to be more or less enlargement of the spleen ; and the his- 
tory of the case, with a knowledge of the existence of malaria 
in the neighborhood where the patient has recently sojourned, 
will, by the help of the rule of exclusion, aid in reaching a satis- 
factory conclusion. In a typical case of intermittent, the diag- 
nosis is easy. There is a regular succession of phenomena and 
a repetition of these phenomena. In pyemia, the accession of 
the fever observes no regularity and there is no complete inter- 
mission. The temperature in pyemia never approaches the 
normal, while in intermittent fever there is a period of complete 
defervescence. Remittent fever usually has but one chill, 
while in intermittent fever a chill inaugurates each paroxysm. 

In the hectic fever which accompanies pulmonary phthisis, 
the paroxysms occur more often in the afternoon than the fore- 
noon, and the intermissions are incomplete. The question^ 



INTERMITTENT FE VER. 633 

however, is as a rule easily settled by physical exploration, for 
in tuberculous disease the physical signs are seldom wanting. 

Prognosis. — In the pernicious variety of intermittent fever, 
or, rather, the pernicious form of malarial poisoning — for there 
is, in such cases, seldom more than a single paroxysm — the 
prognosis is very grave. Fortunately, congestive chills — for 
such in reality they are — are not common, except in certain 
restricted regions of the extreme south. In more northerly 
latitudes the fever is of the benign form and seldom results 
fatally. The cachexia which is left by the poison, and which is 
very hard to eradicate from the system, is its worst feature. 
It not only remains as a constant menace to the health for an 
indefinite period, giving to each intercurrent disease a more 
serious aspect, but it lays the foundation for an innumerable 
train of chronic ills that make life a burden, if it does not 
materially abbreviate it. Children, however, are less liable to 
be permanently affected by this cachexia than are adults. 
They outgrow it as they mature, especially if a change of resi- 
dence is effected to a non-malarious locality. 

Treatment. — The object of treatment in intermittent fever is 
two-fold : first, to arrest the paroxysms, and secondly, to over- 
come the cachexia. The first is much more easily achieved 
than the second. There is usually not much trouble in stop- 
ping the chills. The greatest trouble is in eliminating the 
poison from the system or rendering it inert. More cases are 
suppressed than cured. For the accomplishment of the first 
object — the arrest of the paroxysms — there are but two drugs 
known that are worth mentioning, viz., quinin and arsenic. It 
was from a study of the action of Peruvian bark, and the aggra- 
vation which he witnessed from the use of it in toxic doses, 
that the master mind of Hahnemann first conceived the law of 
similars, which is the foundation stone of ourschool of practice. 
Quinin will produce in a healthy organism all of the essential 
phenomena of intermittent fever — the chill, fever, sweat. It is 
therefore truly homeopathic to this portion of the disease, and 
if given in the beginning of an attack, or during an intermission, 
it will ordinarily prevent or arrest the succeeding attack. But 
it will not always do it, probably because it is not always given 
in appropriate doses. And it will not remove the underlying 
cachexia. For this latter purpose, a close study of the materia 
medica will have to be made, and the curative remedy will have 
to be selected with due regard to the individual case and the 
totality of the symptoms. In ordinary cases the dose of quinine 
— graduated by the age of the child — will be from one to three 
grains, repeated every one, two or three hours, according to the 
severity of the attack. The most effectual time to administer 



634 THE DISEASES OF CHILDREN. 

it is during an intermission, and to get enough of the drug into 
the system to accompUsh the desired object, it should be given 
frequently or freely ; its use should then be suspended until 
the next intermission. The great objection to quinin as a 
remedy for children is its taste. It is intensely bitter, and 
there is no known means of disguising it so as to render it pal- 
atable. It cannot be given per rectum on account of the irri- 
tability which it excites. It is said to act well as a tonic when 
given endermically, i. e., by inunction ; but the skin will not 
absorb enough of it to act as an anti-periodic. The use of licorice 
or other menstrua only increases the bulk of the dose without 
materially modifying its taste. The best way is to give it iri 
solution or wafer, and follow its administration with some fruit 
jelly or orange juice, to get rid of the taste left behind. 

In cases where the stomach will not tolerate quinin, we can 
give the next best drug, which fortunately is tasteless, or nearly 
so. We refer to arsenic, or arsenicum, as we prefer to call it. 
In irregular cases, or those which differ from the typical form, 
in having the chill omitted or a prolongation of the other stages, 
this remedy is even better than quinin. 

In grave cases, where quinin is inadmissible, and we want to 
check the paroxysm, we may give an infant under six months a 
drop of Fowler's solution, and increase the dose to two or even 
three drops with older children. When we give it more fortheca- 
chexia than to arrest the paroxysms, our third or fourth decimal 
trituration will be amply strong enough for all practical pur- 
poses. An admirable preparation, and one which has succeeded 
well in our hands, is the arseniate of qiiinia {chin. ars.). It is 
very successful in masked intermittents, and in mixed types of 
simple intermittent. We give it in 2x or 3x trituration. 

It would be impossible to give the symptomatic indications 
for quinin, for, as Dr. E. W. Jones wisely says: " The most di- 
verse symptomatic series have been cured by it, and in doses 
varying from the truly infinitesimal to twenty-grain doses of 
the crude drug. A remedy which is so universally used as 
quinin can scarcely have defined indications that will cover all 
of its apparent range." It does not seem to have any effect 
over the cachexia, unless it be to aggravate it, and never should 
be given except for its well-known anti-periodic power. To 
overcome the cachexia there are other drugs which will follow 
either quinin or arsenicum, and may be given with good pros- 
pects of success. 

Arsenicum alb. — Increased secretion of acrid, corroding tears; 
face pale, waxy and expressive of suffering ; tongue furred, 
with red streak in middle and red tip ; excessive thirst ; drinks 
often, but little at a time ; drinking cold water does not satisfy 



INTERMITTENT FEVER. 635 

and causes nausea ; no appetite, with nausea when time for fever 
to return ; violent pain in region of stomach ; stools dark, bloody, 
watery, offensive and very acrid, excoriating the anus and but- 
tocks ; pulse small, quick, weak, irregular and scarcely percep- 
tible ; excessive weakness and prostration ; intensely restless 
and nervous ; sleep disturbed, broken with moanings as if in pain ; 
cold, clammy, offensive perspiration with great thirst ; yawnings 
and stretchings before chills ; paroxysms irregularly developed ; 
chills may predominate and fever be entirely absent, or heat 
and fever and profuse sweat, but no chills ; all symptoms worse 
at night and from cold, better from warmth in general. Espe- 
cially useful in tertian types. 

Belladoniia. — Quarrelsome, irritable temper ; eyes red, hot 
and sparkling, pupils dilated, intolerance of light, profuse bland 
lachrymation ; face intensely hot and red ; throbbing and bound- 
ing of carotids; tongue dry, red, hot, with white streak in cen- 
ter; intolerable thirst for cold water ; sharp, painful stitches, 
coming and going like a flash ; stools slimy, bloody, with hard 
lumps mixed with green mucus ; pulse full, rapid, hard and 
bounding ; spasms, convulsions ; restless, throws body back- 
ward and forward ; skin hot all over, with perspiration beginning 
at the feet and extending upward ; starting in sleep, with jerk- 
ings of the head and feet ; sweat stains the bed linen. Espe- 
cially useful in the quotidian and congestive types of the inter- 
mittent. 

Bryonia. — Very irritable, sullen and frightened ; violent throb- 
bing headache, with pains down the neck, worse mornings ; 
face hot and with circumscribed red spot over malar bones ; 
excessive thirst for immense quantities of cold water ; tongue 
coated with heavy white fur, tip moist and red ; nausea and 
vomiting, relieved by large quantities of cold water ; pressure in 
stomach after eating causes great anxiety and distress ; diar- 
rheic stools of offensive, pasty, acrid matter, or constipation, 
with hard, dry stools passed with difficulty ; dry, short, violent 
cough ; exhausted and weak ; stitches in joints and various 
parts of body, worse on slightest motion and touch ; chill begins 
at tips of fingers and toes, thence spreading over body ; chills 
are creeping rather than shaking ; sweats on side laid on ; per- 
spiration sour, oily, profuse, offensive, and easily excited. 

China ars. — Irritable, wants to be let alone ; face pale and lips 
blue ; tongue coated brown ; excessive thirst, which relieves the 
nausea and vomiting ; pulse small, weak, irregular and very 
high (200) ; extremities cold, like ice ; chill in morning at vari- 
able hour, followed towards night by intense fever ; prostra- 
tion ; spasms. Useful in the masked and poorly developed 
intermittents. 



G36 THE DISEASES OF CHILDREN. 

China siilph. — Mind first bright and excited, later, moody, 
dull and irritable ; ringing and roaring in ears ; profuse epistaxis 
in morning ; face swollen, dirty and with sickly expression ; 
tongue swollen, flabby and coated with thick yellow fur ; great 
thirst, but no appetite; vomiting of sour, intensely bitter bile ; 
painful enlargement of the spleen ; dysenteric stools, stools soft, 
dark, frothy and accompanied by large quantities of offensive 
flatus ; urine high-colored and deposits heavy brick-dust sedi- 
ment ; all senses excessively acute ; very weak and prostrated 
after stools ; chills occur at same hour with clock-like regular- 
ity; stage of fever gradually passes into perspiration, with in- 
tense thirst, which is greatly relieved by large quantities of 
water. 

Cina. — Ill-humored, cannot be quieted ; constantly boring and 
picking at the nose with the fingers ; tongue clean, but very 
painful ; excessive appetite all the time, is hungry after eating ; 
intense nausea and retching, vomiting only mucus ; thin, watery, 
painless diarrhea ; face is pale, lips blue, heat and redness on 
cheeks ; perspiration on forehead, face and hands ; feels chilly, 
even when near a hot stove. 

Eupatorium perf. — Intense aching in all the bones of the 
body ; intense thirst for cold water, which causes vomiting ; 
vomiting of dark-green, very bitter mucus, which causes great 
weakness ; cannot bear weight of clothes over hepatic region ; 
morning diarrhea, with burning in anus and rectum ; back and 
limbs feel as if beaten and are very painful; thirst before chill 
and continuing during the chill and fever ; vomiting of bile after 
chill ; shivers all out of proportion to the degree of chilliness ; 
chill in morning one day and afternoon the next day; sweating 
stage may be very profuse or entirely absent. 

Gelsemiiun. — Great mental apathy or is very nervous; face 
flushed and hot ; tongue coated yellowish white ; pulse rapid 
with increased arterial tension ; relaxation and prostration of 
entire muscular system ; chill begins in hands and feet and ex- 
tends to the back; fever very high, but no thirst ; the intermis- 
sions may be very marked or entirely absent ; chill usually be- 
gins in evening ; very restless and sleepless. 

Ipecac, — Very peevish, irritable and cries constantly; face is 
very cold and sunken ; intense, painful and long-lasting nausea 
and retching continues through all the stages ; saliva increased 
and runs from the mouth ; great weakness, with jerking and 
twitching of the arms and legs; intermissions so poorly marked 
as to be unnoticeable ; body feels cold, yet there is high fever ; 
profuse, sour-smelling perspiration which stains linen yellow. 
Useful after abuse of quinin. 

Natriun miir. — Intense congestion of the head and face, face 



INTERMITTENT FEVER. 637 

very shiny ; lips dry, cracked and ulcerated ; very bitter, salty 
taste in mouth mornings ; tongue coated white, with sensa- 
tion as if something was on it ; violent, unquenchable thirst for 
immense quantities of water frequently renewed ; vomiting of 
the water soon after it is drunk; intense burning pain in ure- 
thra, so that child screams when urinating ; urine very pale, and 
copious, uric-acid sediment ; rapid, weak, intermittent pulse ; 
chill in mornings, begins in hands and feet, nails very blue ; 
chilly stage passes directly to the fever ; the chill is long-lasting, 
body feels very cold, but internal heat. 

Nux vomica. — Irritable and peevish ; dizziness with pain in 
head ; tongue thickly coated white, with offensive breath ; vom- 
iting of very bitter, sour mucus ; intense thirst, which is satis- 
fied by milk; diarrhea in morning, with dark-colored stools, or 
constipated and stools light and very hard ; severe, long-lasting 
chills, preceded and followed by heat ; chills are accompanied 
by shakings of the whole body, with pale or blue nails ; chills 
so severe as not to be relieved by heat and great quantities of 
clothing, shivers on slightest motion ; heat, without sweat, and 
cannot uncover without shivering ; sour, offensive, profuse 
perspiration after fever. 

Pulsatilla. — Fretful, anxious, and easily frightened ; dizziness 
and pain in the head, with nausea, which is relieved by lying 
down ; tongue dry, white and covered with a thick, tenacious 
mucus; disgust for meat and fatty foods; painful diarrhea, 
stools mixed with green mucus, or only mucus; involuntary 
passage of copious, pale urine; palpitation in pulse felt in ab- 
domen ; yawns and is very sleepy during the day, wakeful at 
night ; chill in afternoon, begins over abdomen and extends to 
back ; fever is intolerable, begins in hands ; venous congestions, 
no thirst ; profuse sweat on one side onh/. Especially useful 
in relapses from dietetic errors. 



CHAPTER IV. 

RHEUMATISM. 

Acute rheumatism is not, strictly considered, a disease of 
early life. It does not belong especially to any age, or sex, or 
nationality. But when it occurs in infancy or childhood, it 
exhibits certain peculiarities and is attended with certain dan- 
gers, which render its brief consideration here imperative. So 
often does it affect the heart in childhood, causing inflamma- 
tion of its valves, that endocarditis and rheumatism are almost 
synonymous terms. This tendency of the disease to molest 
the sero-fibrous tissues is so universal and so marked that any 
considerable disturbance of the heart's action always creates a 
suspicion of a preceding attack of rheumatism, and in the large 
majority of cases, if the family history be traced back, the sus- 
picion will prove to have been well founded. Nor is this due 
to the preponderance of rheumatism over other constitutional 
or general maladies in parents, but rather to the fact that the 
rheumatic diathesis is one which is readily transmissible, and 
children of rheumatic parents are very prone to have endocar- 
dial trouble, notwithstanding the fact that the rheumatism from 
which they have personally suffered may have been so slight 
and transient as to have been entirely overlooked. Children 
are frequently brought to the physician's ofifice or to the out- 
door clinics, with a well-developed mitral lesion, whose parents 
will insist that they have never had an attack of rheumatism 
or anything like it, unless ''growing pains" might be called 
such. Close questioning, however, will elicit the fact that these 
same children have more or less frequently complained of va- 
grant pains here and there, stiff neck, lameness, etc., which were 
so trifling and of such short duration that little attention was 
paid to them. 

Inspection of the body will reveal the presence here and 
there of subcutaneous nodules — small bullae — about the vari- 
ous joints. 

These inconspicuous masses — frequently more palpable than 
visible — are found about the elbow, the melleoli, the margins of 
the patella and elsewhere ; they may be solitary or in crops, are 
painless, and appear and disappear in the course of a few weeks, 
although they sometimes remain for months. They are not 
(638) 



RHEUMATISM. 639 

pathognomonic of rheumatism, but are so commonly present 
in the rheumatic constitution, that they possess considerable 
diagnostic importance in doubtful cases. Drs. Barlow and 
Warner have shown that they are almost invariably associated 
with disease of the heart, and usually in connection with some 
progressive form of disease. Prof. E. M. Hale has so admira- 
bly covered the cases of heart affection from rheumatic and 
other causes, that nothing more need be said here upon that 
subject. It is only mentioned now to call the reader's atten- 
tion to the subject and direct him where to find it fully 
discussed. See page 383 et seq. 

Of rheumatism, in general, as manifested in early life, it may 
be said that children suffer, as a rule, less intensely and for a 
shorter period than do adults. The pain is generally less 
severe, and the edema about an affected joint is usually less. 
Indeed, the great majority of children affected with rheumatism 
make so little complaint about acute symptoms, that there is 
far more danger of overlooking the affection than of mistaking 
it for something else. 

The copious acid sweats, which are so common in adults 
affected with rheumatism, are almost unknown with children. It 
must not be inferred from what has been said that these trifling 
attacks are to be ignored or treated lightly, for however insig- 
nificant the attack may be it is liable to produce serious and 
permanent heart damage. This is the more true the younger 
the patient. The so-called "growing pains;" a slight swelling 
of a single joint ; a transient pain in the intercostals ; pleurisy, 
pericarditis, pleurodynia, are all indicative of the rheumatic 
diathesis. 

It is plain from this description that the symptoms of acute 
rheumatism in early life are often indefinite in character, but 
none the less serious in import. But children — even young 
infants — do have exceptionally the same form of rheumatism 
as adults, attended with a moderate amount of fever, with a 
joint or joints which are painful, hot, red and swollen. The 
sweUing is due to inflammatory edema of the tissues in and sur- 
rounding the joint. This effused fluid is for the most part 
serum, and resembles the effusion of pleurisy. Like the pleu- 
ritic exudation, it may contain a few globules of pus, and in rare 
and exceptional cases the amount of pus may be so great as to 
constitute a true arthritic abscess. In most cases, however, 
the exudation is mainly serous, and hence is readily absorbed. 
The intensity of the pain is only felt when the affected limb is 
moved or the joint pressed upon. Sometimes rheumatism 
affects but a single joint of one of the extremities, but occa- 
sionally it invades the trunk and involves the articulations of 



640 THE DISEASES OF CHILDREN. 

the vertebra, the symphysis pubis, or the costo-chondrals. 
There is great tendency in rheumatism to wander about so that, 
as the disease abates in the articulations first affected, it re- 
appears in others either near or remote. Fortunately for the 
patient, it is rare that more than two or three joints are in a 
state of active inflammation at the same time. 

In cases where the rheumatism is secondary to some other 
complaint, such as the eruptive fevers, it commonly affects only 
a few joints, often but a single one, and this is attended by but 
slight swelling and redness. Fluctuations are common, and 
just as the patient seems about to recover, the pain and asso- 
ciate phenomena jump to some hitherto unaffected joint or 
tissue, and thus the affection is prolonged. More or less stiff- 
ness is commonly left in the joints which have been involved, 
and this may remain for some considerable time, but is seldom 
permanent, unless the disease itself becomes chronic. 

Treatment. — The treatment of rheumatism may be properly 
divided into, first, prophylactic ; second, palliative ; and third, 
curative. The youthful subjects of rheumatism are usually 
anemic and sensitive to atmospheric changes. This is more 
especially true of those who inherit the rheumatic tendency. 
Such children require to be well clad with woolen garments, 
and their feet should be well protected against dampness. 
Their diet should be carefully regulated and restricted in the 
matter of sweets and all other fermentable foods. The diges- 
tive organs of these children are easily upset, and indigestion 
or anything which reduces the system below par is deleterious. 
The rheumatic child easily takes cold, and is exhausted with 
equal ease. Exercise should therefore be moderate. Both 
study and recreation should be kept within judicious and safe 
limits. Everything, in a word, should be done to keep the 
child well in a general way. It goes without saying that a dry 
and equable climate is better for rheumatic subjects than a 
damp and changeable one. 

Palliative treatme^it consists in swathing the affected parts 
with wool or cotton, which may be kept warm by being fre- 
quently reapplied. Hot fomentations with witch hazel and 
water — half and half — are usually very grateful. All repellant 
applications, as cold or irritants, are dangerous, since they in- 
vite complications. Absolute rest is every way essential. The 
diet should be sustaining, but at the same time bland and un- 
stimulating. The bowels should be kept open by the use of 
fruits, etc., and if necessary, by the additional use of supposi- 
tories or enemata. 

Curative treatment. — Rheumatism is universally conceded to 
be caused by an excessive amount of acid in the blood, and 



RHE UMA TISM. 641 

therefore the exhibition of alkalies seems to be founded on 
reason and sense. The alkaline treatment is not only theoret- 
ically correct, but clinical experience endorses the theory. The 
use of acetate of potash and bicarbonate of soda for this purpose 
has given place to the salicylate of soda treatment, which is 
undoubtedly preferable as being more speedily efficient. By 
some the salicylate of lithia is preferred. Either drug may be 
given to a child of from three to five years, in doses of two and 
one-half grains every three hours, for three or four days, after 
which it need not be repeated oftener than three times a day. 
It m.ay be given in syrup or any other available medium. To 
children past six years of age five grains may be given at a dose 
without a. particle of danger. While salicylic acid combined 
with soda or lithia salts is being given for its chemical effects, 
the homeopathic remedy should be given with special reference 
to the local manifestations of the disease. The selection of 
the drug for the case in hand will depend on the site of the 
inflammation, the time of greatest aggravation of pain, the 
general condition of the patient, etc., etc. 

D. C— 41 



CHAPTER V. 

ADENITIS ; LYMPHADENITIS (NON-SPECIFIC INFLAMMATION OF 
LYMPHATIC GLANDS). 

The tendency of glands in the neck and elsewhere to take 
on congestion and inflammation in certain persons, especially 
children, who either have inherited or acquired the scrofulous 
or strumous taint, is universally recognized, and has been men- 
tioned by nearly all medical writers since the days of Hippoc- 
rates. Sometimes this tendency is the only clue we have to 
the scrofulous diathesis ; but more often we have, sooner or 
later, the symptoms described in the last section, and are com- 
pelled to recognize the glandular swelling as part of a consti- 
tutional dyscrasia, whose depraved influence and tendency are 
as widespread as the bounds of the organism. But there are 
other cases occurring every now and again, in the practice of 
every physician of large experience, in which there is swelling 
of the lymphatics of an acute or chronic character, with but 
little tendency to suppuration, and in children who show no- 
where else, and in no other way, any signs of tubercle, scrofula 
or struma. They neither have eczema nor catarrh, nor do they 
have the general appearance of those who are the manifest sub- 
jects of hereditary taint. All that can be said of them is that 
they are subject to glandular swellings. Why, in such cases, 
the cervical glands are more apt to be implicated than others, 
has been a matter of much speculation. That thej^ are so, is 
beyond question. Treves gives the following table of the 
comparative location of glandular disease: 



Neck alone 131 

Neck and axilla 12 

Groin alone 6 



Axilla alone 4 

Neck and groin i 

Neck, groin and axilla i 



Some authors endeavor to account for this great preponder- 
ance of cases involving the neck by their close proximity to the 
tonsils, which are the largest aggregation of adenoid tissue in 
the body ; and this theory receives much plausibility from the 
fact that these glands are so frequently enlarged whenever the 
tonsils are inflamed. But tonsilitis is not the only proximal 
inflammation or irritation that may give rise to enlargement of 
the cervical glands. Eruptions on the skin, face and scalp, 
(642) 



ADENITIS; L7'MPH ADENITIS. 643 

coryza, diseases of the ear, and even dentition may also act as 
indirect causes. Gastric derangements, also, should be classed 
in this category, but beyond doubt '' taking cold " is, more often 
than anything else, the immediate or exciting cause. That the 
victims of adenitis are generally delicate, highly organized and 
sensitive children, is true, but according to the accepted pathol- 
ogy of that disease, mere delicacy of organism or mere depres- 
sion of vital powers would not be sufficient to produce the con- 
ditions known as scrofula. Even adults in ordinary health, and 
who have never exhibited symptoms that could by any possi- 
bility create a suspicion of scrofulous inheritance, may have 
temporary engorgement of a gland, and that engorgement may 
go on to inflammation and suppuration. 

What is true of adults, is especially true of children, in whom 
the glandular structures are proverbially sensitive to peripheral 
irritation or to reflex influences through the sympathetic nervous 
system. This will be more readily understood by recalling certain 
facts from anatomy and physiology relative to the lymphatic 
glands and their function. The lymphatics themselves origi- 
nate in the areolar interspaces and are everywhere present. 
They do not go far from their point of origin before they meet 
other lymphatics, with which they coalesce and expand into a 
lymphatic gland, with efferent ducts or lymph channels to con- 
vey the lymph corpuscles into the general circulation. Just 
how these lymph corpuscles originate is not known, but every 
efferent duct is filled with them, and anything which interferes 
with their progress toward the general blood-stream is produc- 
tive of mischief. In children the waste and repair of tissue is 
very active, and the function of the lymphatics is to pick up 
waste products, which are mostly albuminous, and conveying 
them first to the lymphatic glands, bring them ultimately to the 
general circulatory system. All effete material or foreign sub« 
stance which has found its way into an areolar interspace, is 
taken up by the open mouths of the lymphatics and passed 
through the glandular mechanism. Now, bland soluble mat- 
ters, when thus taken up by the lymphatics, pass on without 
hindrance and without producing congestion or irritation. But 
it is different when the matters in transit, instead of being 
bland and soluble, are insoluble or irritating. Then the gland 
is liable to first irritation and then inflammation. 

When the surface of the body is chilled, as from cold, all of 
the superficial vessels are contracted in consequence, the lym- 
phatics as well as others. The effect of this contraction is to 
congest the glands by preventing the onward flow of the 
lymph corpuscles. Hence we see how easily from cold a gland 
may become engorged, congested, and then inflamed. 



64-1 THE DISEASES OF CHILDREN. 

In the neck the cervical glands are large as well as numerous- 
being made up of innumerable small glands conglomerated to, 
gether. All glandular structures are in the closest relations of 
sympathy, and so we see how an inflammation of the tonsils, 
to use these organs again by way of illustration, may extend to 
the adjacent glands of the neck. 

In scrofulous subjects, the processes of metabolism are im- 
perfectly performed, the elaborated tissues are only partially 
elaborated, and the waste products are only partially soluble. 
Hence such persons have constant trouble from glandular dis- 
ease. But others, also, are liable to glandular engorgement 
from cold or peripheral irritation, although at other times and 
under other circumstances the lymphatic system is in perfect 
working order, and the processes of metabolism are carried on 
in a physiological manner. In scrofulous subjects, glandular 
swellings are general in their causation, while in non-strumous 
subjects these causes are mostly or entirely local. Clinical ex- 
perience teaches that when inflammation is set up in a gland 
the changes effected therein are manifested first in the deeper 
portions of the glandular structure, beginning in the medulla 
and extending thence to the cortical portions, and never invad- 
ing its capsule. Sometimes, when the gland is merely con- 
gested or engorged and not inflamed, the obstructing material 
only undergoes partial absorption and remains a fibroid callus. 
A gland is then said to be indurated, and may remain in this 
condition indefinitely. 

In other cases, the gland becomes inflamed and pus is 
formed ; which finds a superficial outlet or burrows into the 
deep-seated structures, before discharging into some internal 
organ or tissue. We have entered into this somewhat elaborate 
argument to prove that all glandular swellings are not necessa- 
rily scrofulous or tubercular in their nature ; that certain glands, 
especially those in the neck, may be temporarily engorged, and 
this engorgement may go on to inflammation and suppuration, 
either of the gland itself or of the tissues around it, without 
implying any perversity of constitution or any morbidity of 
histological processes or products, other than those of a local 
and generally ephemeral character. 

Symptoms. — There is one point of difference between gland- 
ular infiltration of strumous origin and that non-specific form 
which we are now considering. The latter is always acute and 
accompanied with acute symptoms, while scrofulous glands are 
proverbial for the chronic and indolent character of their ail- 
ments. The more marked the strumous diathesis, the more 
true is this observation. 

A scrofulous gland may show no symptoms of its distress in 



ADENITIS; Ll'MPH ADENITIS. 645 

pain, or heat, or other signs of inflammation. A lump or tumor 
of considerable size is often the first intimation of glandular 
disturbance. This insidious history is not characteristic of 
acute non-specific adenitis. In this variety of glandular inflam- 
mation, no sooner does the gland begin to swell than it becomes 
tender and sensitive to the touch. In many cases there is some 
febrile disturbance and there may be headache and vomiting. 
The gland itself does not usually become red and inflamed on 
the surface until some days, or even weeks, have passed. Be- 
sides being tender and sensitive to pressure, it gives rise to but 
little inconvenience. It is very subject to exacerbation, one 
day being larger and more tender, and the next day, perhaps, 
behaving as if resolution were progressing rapidly. The 
formation of pus, if it takes place at all, does so very slowly, 
and may threaten many times before all hope need be aban- 
doned of its prevention. 

Sometimes a single gland or a whole string of glands may be 
affected at once ; or a number of neighboring glands may be 
simultaneously involved, and the whole number be matted 
together in a common swelling. When inflammation succeeds 
to engorgement, it is always of low grade and the formation of 
pus is not accompanied by any of those symptoms which ordi- 
narily attend suppuration. It is for this reason that the older 
writers referred to a suppurating gland as a " cold abscess." 
After an indolent and chronic career of weeks, or sometimes 
months, the affected glands either slowly undergo resolution 
and disappear, or become acutely inflamed and suppurate. In 
some cases the adenitis may be of only short duration, lasting 
but a few days ; but the tendency is as stated above, and the 
average duration is weeks rather than days. 

The tendency to adenoid inflammation is sometimes met 
with in adults, usually males, and may, therefore, be of lifelong 
duration ; but as a rule, it rarely persists after puberty. When 
occurring in delicate children in early life, it is reasonably safe 
to expect that, with better health and the progress of adoles- 
cence, the glands will be less sensitive and less liable to acute 
inflammation. 

Treatment. — While the affection here described is manifestly 
not due to scrofulous or other constitutional taint in the blood, 
it is usually if not always associated with more or less general 
derangement of the system. It occurs most frequently in chil- 
dren whose digestive organs are easily disturbed, and who, from 
too rigid confinement indoors or from constitutional delicacy, 
are very subject to colds. Glandular inflammation, too, is 
frequently commingled with some other disease, as scarlet 
fever, measles, diphtheria or other affections of the throat. 



646 THE DISEASES OF CHILDREN. 

In such cases, it is to be regarded as a complication and 
treated as such. 

When occurring idiopathically or in connection with an or- 
dinary cold, the treatment should be more hygienic than medic- 
inal. Cool sponge baths, frequently repeated, are very useful. 
These children do not bear confinement indoors, either in 
school, or in "apartments," which are now so fashionable. 
They should be out of doors as much possible, and be fed on 
coarse but wholesome food. If there is such a thing as ''hard- 
ening " delicate children by exposure to the vicissitudes of the 
weather, it should be judiciously tried in cases of this kind. 
Coddling only makes matters worse. Exercise, either active 
or passive ; a due regard for diet ; and plenty of fresh air are 
alone sufficient, in many cases, to overcome the tendency to 
glandular stenosis and consequent inflammation. When the 
glands do become swollen and inflamed, they should be rubbed 
with some warm unguent, like vaselin or camphorated oil. 
Even gentle friction with the hand, continued for some minutes 
and frequently repeated, will be found serviceable. 

There need be felt no fear of " scattering " the disease. Such 
a thing is impossible. There is no more danger of such a re- 
sult than there is of scattering a mastitis, for the two affections 
are very similar in causation and course. 

Indeed, the medicinal treatment is very similar. In both, 
the first remedy to be thought of, after aconite, for the attend- 
ant fever, is hepar siilpJiur. In cases of chronic character, 
with little or febrile accompaniment, hepar, given three or four 
times a day, will often bring about resolution in a very short 
time. As the subjects of adenitis are usually small eaters, and 
of low vitaUty, we are in the habit of giving them, by way of 
a tonic, and in the absence of more clearly indicated homeo- 
pathic remedies, chin, arseniate 3x, a two-grain powder three 
times daily, half an hour before eating. This remedy is a 
splendid appetizer and increases the vis medicatrix natures. 
Other remedies of value are, mercuritcs, apocymivi, Phytolacca, 
thuja, and sulphur. The glands themselves should never be 
poulticed, or swaddled, or opened with a lance, until there are 
unmistakable signs of pus within or about the glandular 
structure. 



PART XL 

AFFECTIONS OF THE NERVOUS SYSTEM. 



CHAPTER I. 

INTRODUCTION. 

Diseases of the nervous system, especially functional, and 
often organic, might be prevented by judicious advice on the 
part of the physician, followed by proper care on the part of 
parents. 

As to attention to clothing, diet and ordinary sanitary meth- 
ods, much has been written and taught. Physicians are well 
qualified to, and do advise in these matters. 

We are not, however, doing our whole duty or fulfilling our 
responsibility, if we neglect to make any effort to guide parents 
in the training of their children in all respects. We are apt to 
feel that we have nothing to do with the moral health, with 
the temperament, with the discipline, or in fact with anything 
that is not actual sickness, actual disease. It is true, however, 
that the highest, the grandest function of the physician is to 
preserve health and to prevent sickness. There is no doubt 
that in these days very much can be done as regards the spe- 
cial class of diseases wdth which we are dealing. 

The time to commence the prophylactic treatment is soon 
after birth. First, teach the babe regularity of habits, as to eat- 
ing and sleeping ; in this you lay a foundation for self-control. 
As the baby grows there should, at all times, be gentle but firm 
control exercised, insistence on method and order in its little life. 

Through childhood order, method, self-control, thought and 
care as to the comfort and feelings of others, combined with a 
just regard for, and insistence on, self-comfort and rights, should 
be taught. No one can control him or herself that has not 
learned to obey those having a right to command. 

The mental development should always be under the general 
supervision of a competent medical man. The hereditary ten- 
dencies, mental and physical, must be carefully considered, and 
the teaching of the child regulated accordingly. The child of 

(647) 



648 THE DISEASES OF CHILDREN. 

slow, steady nature, with no predisposition to disease, ought 
to be encouraged in its natural efforts at learning from the very- 
beginning of mental activity. On the other hand, the child 
who is at all predisposed to tuberculosis or struma of any kind, 
or shows the tendency to be nervous, should not be encouraged 
in learning. The child that is particularly bright and learns 
readily, remembers well, shows at an early age reasoning 
powers, must be discouraged in learning. With this class of 
children, parents are apt to claim that they cannot prevent it. 
The facts are that they and their friends, by oft-repeated com- 
mendation and praise, stimulate the pride of the child, and in 
this way encourage when they think they are trying to dis- 
courage. It is very natural to be proud of one's own child, but 
the wise doctor will show the parent the danger, and the wise 
parent will heed the warning. 

From birth to puberty develop the physical, and you will be 
able to develop the mental later. The child that commences 
school life at nine years of age will, at twelve, usually be on a 
par in classes with those who commence at six or seven. The 
comprehension of all that is taught, instead of simply using 
memory, is a sufficient explanation. The physician should see 
that the child, male or female, is early carefully guarded against 
pernicious sexual teaching, either by nurses or companions. 
The false ideas and the wrong hesitancy on the part of parents 
to talk with their children on these matters, renders it impera- 
tive that the doctor should see that it is not neglected. The 
natural feeling that " My child could not and would not do any- 
thing of this kind," makes the duty of the medical man, whose 
experience shows him that no class escapes, absolute in his 
insistence on watching carefully, as to the sexual habits of 
children. 

Be sure the baby, and as it grows older, the child, is always 
well and regularly nourished, and has plenty of outdoor exer- 
cise. Do not allow too much clothing, nor allow a child to be 
too thinly clad. See that houses where there are children are 
not made furnaces to reduce the natural resistance. 

GENERAL REMARKS AS TO THE DIAGNOSIS OF NERVOUS 

DISEASES. 

Careful work, with close attention to minutia, is the only 
road to success in diagnosticating this class of diseases. In a 
very large percentage of the cases, the diagnosis must be made 
by exclusion. Make in every case a careful, written history. 
First, as to any possible family taint in any branch of the an- 
cestry, including dissipation of any kind. Second, as to any- 



DIAGNOSIS OF NERVOUS DISEASES. 649 

thing of an emotional or physical nature occurring during life 
in utero. Third, as to the character of labor, whether any 
occurrence that might produce injury, rendering the child sus- 
ceptible to nerve troubles. Fourth, follow carefully and mi- 
nutely the life of the babe as to nutrition, sleep and regularity 
of function ; the kind of care and discipline it has had. Fifth, 
as to each attack of sickness, severity, duration, exact charac- 
ter, and the recovery from each, whether complete and speedy, 
or tardy, and followed by sequela. Sixth, as to any injury, 
getting all the particulars as to how injured ; the immediate 
effects, and possible later results. Seventh, as to the very first 
signs of the trouble for which you are consulted, following it 
step by step very carefully to the present time. 

Having completed the history, make a careful physical 
examination of the entire body; note the general appearance, 
the facial expression, the contour of the head, the appearance 
of the eyes, as to size, shape, concordance of the pupils, and 
test the vision (if the child is old enough). Examine the nasal 
passages and the throat; auscultate and percuss the chest and 
abdomen carefully; inspect the spinal column to determine as 
to any curvature and as to tenderness over the spinous pro- 
cesses ; examine closely the sexual organs for any signs of irri- 
tation, for elongated or adherent prepuce, or an adherent 
clitoris. Note the plumpness of the legs as compared with 
the upper portion of the body. Test for the reflexes, both 
superficial and deep. Examine the anus, and if there is any 
evidence of disturbance of the bowels in the history, or any 
signs of irritation about the anus, examine the rectum ; this is 
often essential, even in very small children. An analysis of the 
urine ought to be made in every case. For this purpose, the 
entire quantity for twenty-four hours should be collected. 
There is much to be learned, regarding the nerve condition, 
from a complete quantitative analysis of the urine, and, not 
infrequently, knowledge that will lead directly to the therapeu- 
tic and hygienic measures essential to the speedy cure of the 
case. For special instruction as to this part, you are referred 
to Part VIII. 

There are many things rendering the examination of children 
much more difficult than of adults. They are, as a rule, much 
more emotional ; are unable to give us clear and comprehen- 
sive descriptions of their feelings ; they do not locate sensations 
as well, and are inclined to exaggerations of expression. Ob- 
jective symptoms have to be relied on to a great degree. Long 
experience and habits of close observation alone can enable the 
physician to approximate in each case the value of expressions 
of pain, or emotional disturbance. 



650 THE DISEASES OF CHILDREN. 

Marked irregularity in the shape of the head, or great dispro- 
portion between the size of the head and of the body in a child, 
should always be carefully considered with relation to what 
may be indicated as to the future growth and development, 
mentally and physically, as well as in relation to their signifi- 
cance in pointing to a predisposition to certain diseases. 

There are some special symptoms which it is important to 
note. Strabismus may be temporary or permanent. It is fre- 
quently found in convulsive attacks of every variety ; if lasting 
during the attack only, or a very short time after, it is probably 
simply functional. If, however, it persists for days, a careful 
study should be made as to whether there is any abnormal 
condition in the eye itself sufficient to cause it ; if not, examine 
as to collateral symptoms pointing to disease of the brain. 

Nystagmus may be found as a local chorea, or as a symptom 
of congenital cataract. It is usually a result of cerebral dis- 
order, such as tumor, atrophy, edema, or chronic hydrocepha- 
lus. It is nearly always present in the second and third stages 
of tubercular meningitis. 

The pupils, if of unequal size in a child with normal eyes 
when in health, is a very grave sign in any of the acute cere- 
bral disorders. If they respond to light sluggishly, the indica- 
tion is bad. Impairment or loss of sight is most common in 
cases of thrombus of the cerebral sinuses, in meningitis and 
intracranial growths. 

Delirium in a child is usually indicative of some present or 
approaching febrile disturbance, or of digestive disorder ; but is 
not frequent with cerebral disease, unless of an acute inflamma- 
tory nature. 

Drowsiness may be marked in cases of uremia, or of digest- 
ive disturbance ; is very frequently found to be the result of 
selfishness on the part of the nurse or mother, shown by their 
administering some of the various soothing medicines rather 
than be bothered with the child. After a convulsive attack, 
drowsiness for an hour or two is quite common, and is simply 
the result of a natural reaction from the excessive muscular 
exertion and the disturbance of circulation. If, however, the 
drowsiness is long persistent, evidences of cerebral disease 
should be looked for carefully. Convulsions occurring fre- 
quently, with marked drowsiness during nearly or all of the 
interval, especially if indications of head pain be present, is 
likely to indicate meningitis. 

Paralysis may be the result of the pressure of forceps in the 
delivery, of rheumatic inflammation of the sheath of a nerve, 
of lowered general nutrition, of great prostration, or of cere- 
bral, spinal, or peripheral nerve disease. It may follow convul- 



DIAGJVOSIS OF NERVOUS DISEASES. 651 

sive attacks ; if transitory, is of no special significance, but if it 
lasts a number of days there probably is some intracranial 
lesion present. 

Rigidity may be (especially in children over six years of age) 
hysterical, the result of some reflex irritation, or of some spinal 
or cerebral disease, acute or chronic. A long continued paraly- 
sis is quite certain to be followed or accompanied by a perma- 
nent rigidity and contraction. The rigidity of the muscles of 
the neck, drawing the head back between the shoulders, so fre- 
quent a symptom in various forms of meningitis, if at all well 
marked, is a very serious indication. 



CHAPTER II. 

CONVULSIONS IN CHILDREN. 

Convulsions may occur at any age. In fetal life they are 
not common, but it is probable that they are the cause some- 
times of death in iitero. Attacks during the first week or two 
following birth are probably the result of injury to the brain 
by pressure during labor, whether it be natural or instrumental, 
or of uremia in the mother. They are frequent during the first 
two years of life, and from this time on grow less frequent to 
old age. They are, I believe, always the result of irritation of 
some portion of the central nervous system. Many theories 
have been advanced and experiments made to determine an 
exact center, and the definite character of the nerve action ; but 
up to this time with indifferent success. The disturbance of 
the animal electrical poise, anemia of the brain, explosion of 
nerve force, vaso-motor irritation or paresis, defective cerebral 
nutrition from any cause, have all been advocated by men of 
large learning and special skill in this particular line of study. 
There is one point on which I think all can agree, viz.: that by 
some as yet undetermined process the inhibitory powers of the 
higher cerebral functions are interfered with, and as a result of 
this loss of control, motor, sensory, and vaso-motor centers act 
without coordination, producing violent, irregular contractions 
of muscles, occurring in paroxysms, often with insensibility. 

There is in these cases a predisposition to convulsions, a 
neuropathic temperament. It is claimed by many authorities 
that rachitis is the most common cause. My own experience 
will hardly justify such a conclusion. Rachitic children are 
quite liable to attacks, and a large majority do have convul- 
sions ; but I have seen many more cases where various 
stomachic and intestinal irritations are the undoubted cause. 
Worms, chiefly lumbrici — tape worms being very uncommon 
in young children — and thread or pin worms, are a frequent 
cause. Articles of diet that are particularly indigestible or 
irritating to the gastro-intestinal mucous membrane, or more 
or less completely impacted fecal matter, may also produce 
convulsions. Irritation of the genito-urinary organs, various 
states of the blood, as uremia, and as found at the beginning 
of many febrile attacks, and passive congestion of the brain,, 
(652) 



CONVULSIONS IN CHILDREN. 653 

are common etiological factors. It is now claimed that active 
arterial congestion is never the cause of convulsive attacks. 
General exhaustion from any cause, a profuse and lasting 
•diarrhea, are possibly the most common causes, as are also 
sudden and violent emotions. The hydrocephaloid condition 
and external irritants to any part of the body, and lowered 
nutrition, from whatever cause, will render the child addition- 
ally susceptible. 

The cases due to intracranial lesions, which may occur at any 
age, may be considered under their respective headings. 

It is not at all uncommon for the parents to declare that the 
first attack came on without any previous indication or imme- 
diate cause whatever. By careful inquiry, the physician will 
nearly always find that for some hours or days, possibly weeks, 
the child has been unusually nervous and irritable, or it may 
have been uncommonly quiet and inclined to languor. Possi- 
bly little twitchings of the various muscles of the face, hands, 
or lower extremities were present. In some cases slight 
spasms of a local character have occurred a number of times. 
I believe in very nearly all cases you will be able to learn of a 
more or less marked deviation from the ordinary characteristics 
of the child. In the cases due to gastro-intestinal irritation 
from overloading the stomach, or from improper food, there 
will not usually be marked pain in the stomach or bowels. If 
the irritation vents itself in local pain there is not likely also 
to be reflex irritation. 

The attack itself is likely to be first a paleness of the face, a 
rolling of the eyeballs upward, outward, inward, or downward, 
followed by a stiffening of the body in tonic spasm. There 
may be opisthotonos or simple retraction of the head, or roll- 
ing of the head to one or the other side ; hands may be 
clinched or opened widely, feet straightened out or drawn to 
the right or left side. This will be accompanied by a flushing 
of the face, changing to a bluish or purplish hue ; more or less 
dififlculty of respiration. Following there may be a relaxation 
■of the contractions, or clonic spasms continuing for a short 
period, then gradually growing less pronounced until perfect 
relaxation, and followed, usually, by a sleep of varying dura- 
tion ; preceding the sleep there is a return of natural color to 
the face and one or more long, deep inspirations. All cases do 
not present this entire picture ; there may be anything from 
the simple rolling of the eye to the full attack. When the 
child awakens, it often appears to be perfectly well; but when 
the attack is due to any immediate and temporary irritation, 
there will still be found present some evidences of such cause. 

It will not always be possible to determine at once whether 



654 THE DISEASES OF CHILDREN. 

there is present a true epilepsy, some organic brain lesion, the 
ushering in of some acute disease, the result of some constantly 
acting irritant, or an immediate and temporary irritation. 
Differentiation from true epilepsy is impossible when occur- 
ring in a very young child, or if this is the first attack. In a 
child not over two years of age, who is thoroughly well nour- 
ished, quite fat and robust, it is almost certainly reflex. On 
the contrary, if emaciated and poorly nourished, a tubercular 
condition may be suspected. If a brain lesion be present, the 
convulsion is apt to be partial ; one arm or one leg only being 
affected, often a paralysis of facial muscles, remaining a short 
time, producing ptosis, drawing of the mouth, inequality of the 
pupils, or a general paralysis persisting for many hours or days. 
A strabismus, although not necessarily indicative, yet if at all 
persistent, not having been present before the convulsion, de- 
serves careful attention as to collateral evidences of brain lesion. 
If there be no loss of consciousness, and stupor or great drow- 
siness remains many hours or days, especially if accompanied by 
muscular contractions, there is good reason to fear intracranial 
lesion. It is not common to have a convulsion occur as one of 
the first evidences of an acute disease, yet some children are so 
susceptible to slight irritations that an attack seems to replace 
the chill which so frequently ushers in the disease ; in these 
cases, the evidences of febrile disturbance, and the immediate 
subsequent history, will solve the problem. Much more fre- 
quently we have convulsions in the late stages of acute diseases ; 
they are then always of serious import. If the gums are hard, 
inflamed and swollen, and there is some febrile disturbance, it 
is probably due to dental irritation. 

If there is any discoverable irritation, it is reasonable to con- 
clude that it is a case of eclampsia. Always examine the urine. 
Children very often have uremic convulsions. 

The prognosis in all but the purely eclamptic or reflex cases 
will be considered in other connections. In those of reflex 
origin, it depends upon the possibility or probability of remov- 
ing the cause. If the fit be very severe and of long duration, there 
is danger that emboli, thrombus, congestion, or effusion may 
occur as a result of the convulsion. In babes of a few weeks 
this is very likely to occur, death ensuing apparently as a direct 
result of the convulsion. If the patient is very much exhausted 
from acute disease, or very poorly nourished from any cause, a 
fatal result, while not inevitable, is to be feared. If a convul- 
sion, or series of them, occur in a later stage of any of the 
acute febrile diseases, death is very probable. Marked sterto- 
rous breathing, rapid pulse, or a very pale, livid countenance 
indicates danger. If there be very scant excretion of urine, 



CONVULSIONS IN CHILDREN. 655 

there is serious danger, unless a copious flow of urine of good 
quality in a reasonably short time can be excited. 

In considering the prognosis of convulsive seizures, it must be 
remembered that many cases of imbecility from arrested cere- 
bral development are due to convulsions, in which we are 
unable to find any brain lesion. In ordinary attacks the 
result of reflex irritation, or in rickety children, no such re- 
sult is to be expected, unless the attacks are not only very 
frequent, but of long duration, and followed by marked mus- 
cular weakness, paresis, or long-continued coma or somno- 
lence, showing immediate cerebral affection as a consequence 
of the fit. 

It is not often that the physician arrives in time to find the 
patient actually in the fit. When he does, the most important 
thing is to preserve a calm, well-poised demeanor, and without 
unseemly haste direct the various persons about, to prepare a 
warm bath, to undress the child, procure cold water, blankets, 
towels, etc. It is not a very difficult matter usually to give 
each person present something to do, and in this way it is quite 
possible in most cases to secure a quiet atmosphere about the 
patient, the physician himself keeping a careful, observant 
eye on the patient, watching the exact character of the fit with 
reference to the presence or absence of marked indications of 
cerebral lesion. If the fit has not ceased by the time the bath 
is prepared, immerse the body from the neck down in the warm 
or hot bath, and apply cold water to the head. The water 
should be quite warm, almost hot, but be careful that it is not 
hot enough to scald. I do not give exact temperature, as it is 
unnecessary. Nearly always the attack will cease in a very 
few minutes. Ordinarily, the child may be left in the bath ten 
or fifteen minutes, but if very much exhausted from previous 
sickness, or very poorly nourished, not more than from two to 
five minutes. These baths may be repeated at frequent inter- 
vals, if found necessary. The bowels should always be com- 
pletely emptied with an enema ; and if soon after eating, empty 
the stomach by an emetic. When taken out of the bath, the 
child should be wiped dry quickly, placed in bed and covered 
carefully, in a room well ventilated and not too light. If the 
child is of teething age, examine the gums carefully, and lance 
them if swollen and tense ; in short, see that all immediate 
irritation is removed. 

A dose of castor oil will clear up a case very speedily, if large 
and small intestines are loaded with any irritating accummula- 
tion. It will sometimes be found necessary to administer 
chloroform by inhalation, in order to stop the convulsions, 
or to prevent immediate and frequent recurrence. It often 



656 THE DISEASES OF CHILDREN. 

happens that the immediate irritant cannot be speedily re- 
moved, and there is danger of serious trouble ensuing from the 
frequency and severity of the convulsive attacks ; in these 
cases, I advise the giving of a mixture of sodium brornid and 
chloral hydrate. The formula is : 

Sodium bromid grs. 40 

Chloral hydrate grs. 16 

Aqua distil q. s. %\w. 

Mx. 
Sig. : Give a tablespoonful once every hour or two, till relieved. 

The remedies to be used at this time are, aconite, calcarea 
carb., ca7npJiormono-br ornate , gelsemiuni, santonin, or veratruni 
viride. The physician having the family in charge does not 
do his duty if he fails, in every case to which he is called, to 
make careful inquiry and examination for the cause of the 
particular attack, and as to whether or not there have been 
previous attacks. 

The treatment of recurring cases will be considered in con- 
nection with epilepsy. 

EPILEPSY. 

Epilepsy is a condition of more or less marked loss of con- 
sciousness, recurring at regular or irregular intervals, with or 
without convulsions, not caused by immediate irritation, and 
where the pathological condition producing the attacks is 
unknown. 

This definition excludes a very large percentage of the cases 
usually diagnosed as epilepsy. For practical purposes, the 
only objection to calling all cases of the epileptic class by the 
one term, is the tendency on the part of the physician to be 
satisfied with a diagnosis of epilepsy, and to prescribe for all 
cases their peculiar or special epileptic treatment. 

If, by any means, the physician can be induced to consider 
the attacks simply as symptomatic, and to feel that he has not 
made a diagnosis of the case until he has ruled out all possible 
sources of irritation, the prognosis of this disease or condition 
will be very much brighter, and the percentage of cures can 
certainly be made much larger than at present. There are 
many curable cases allowed to go uncured simply because they 
are called epilepsy and no careful investigation made. If we 
shall be able to make it plain that a disease, whatever its symp- 
toms, is never correctly named except by its pathology, very 
much will be gained. Thus, if we have a case presenting the 
ordinary phenomena of epilepsy, and find that it is due to eye- 



EPILEPSr. 657 

strain — a hyperphoria, for instance — the diagnosis should be, not 
epilepsy, but hyperphoria. I do not claim that the present 
authorities have been in error in including so many and diverse 
pathologies under the one head epilepsy, nor do I believe the 
thoroughly scientific specialist has overlooked the special pathol- 
ogy in his individual cases ; but I do believe the general practi- 
tioner, whose time is fully occupied, will get much better results 
by this classification. The prognosis in pure epilepsy depends 
in the main on the character, frequency and severity of the 
attacks. Many patients will have quite severe and frequent 
attacks for many years, with very little apparent effect on the 
general health, The constant fear of an attack must, of course, 
have a tendency to mental depression, and so in a measure 
unfit the subject for the ordinary duties of life. It is true that 
many epileptics are apparently bright, perfectly able to, and 
do engage in various vocations, but the frequent recurrence of 
attacks does, in a very large majority of cases, cause a corres- 
ponding loss of mentality. In many subjects there is, accom- 
panying each convulsive attack, an actual insanity, lasting from 
a few minutes to some hours. There are a few cases in which 
more or less frequent attacks of acute mania occur at intervals, 
and are of short duration, the patient apparently being per- 
fectly sound mentally between attacks, and with no loss of 
consciousness or evidences of spasms ; these attacks, although 
there are no convulsions, must be considered as epilepsy, un- 
less it is possible to discover a sufficient pathology. There is 
always a liability to idiocy, imbecility, or some form of mental 
incapacity from defective nutrition of the brain, resulting from 
the disturbance of circulation. In a small percentage of cases, 
pathological lesions of various kinds are the direct result of the 
circulatory disturbance of the brain. 

Death as a direct result of epilepsy is not very common, the 
patient usually dying from some other cause. 

Attention should always be called to the danger from acci- 
dent in falling while in the fit. 

The percentage of cures in pure epilepsy, after all the con- 
vulsive cases caused by known pathologies are ruled out, under 
any method of treatment will be small ; but I believe under the 
homeopathic law carefully applied, there is a very decided 
favorable margin as against the anti-spasmodic methods. In 
the treatment of recurrent convulsions, the closest attention 
must be given to every detail in the environment and habits of 
the patient, and the remedy must be selected with the greatest 
accuracy. 

Where the attacks are the result of any reflex irritation, this 
must be removed at the earliest possible moment. For in- 
D.C.— 42 



658 THE DISEASES OF CHILDREN. 

stance, many cases resulting from stomach worms have been 
permanently cured by five-grain doses of scale pepsin every 
two hours. The pepsin should be put in capsules. This 
dose can be given to children over three years of age, while 
for younger children the dose should be from two to three 
grains. 

Whenever a source of irritation is found, lose sight of the 
one symptom, convulsion, and cure the cause, whether it be by 
the administration of medicine, by operative interference, or 
by correction of eye condition. The long or adherent prepuce 
should always be promptly excised, the adherent clitoris liber- 
ated, and the constricted urethra or meatus relieved. Do not 
fail to note and correct any malposition of testicles or ovaries, 
even in small children. Correct as soon as possible any defect 
in refraction with glasses, and be very careful to correct fully 
any muscular deficiency in the eye. While the various hetero- 
phorias are not by any means the cause of all cases, they are in 
a large number, and many can be cured by either the prisms 
or by operation. Fissures in the rectum and anus are much 
more common in children than is ordinarily understood, and 
must be cured at once. 

If the child has received an injury at any time, very careful 
inquiry as to its possible location on the head, and also as to 
the effects or condition immediately following the injury should 
be made. The head must be carefully and minutely examined 
over the entire surface, to ascertain the presence or absence of 
any evidence pointing to a depression at any point. If there 
is a clear case of an injury on the head, followed by severe 
symptoms, such as might be the result of concussion or frac- 
ture, and in addition to this there is found at the point of injury 
a depression, no doubt should be entertained as to the proced- 
ure ; operate at once. I would like here to caution the physi- 
cian as to the necessity of examining very carefully for evidences 
of cranial injury when called to see any child who has had an 
accident. There are a great many epileptics, as well as mental 
deformities and insufficiencies, that could have been prevented, 
had the physician who saw the case, at the time of the acci- 
dent, given it a proper examination. 

If the convulsions are unilateral, or always begin in the same 
set of muscles, and if they become general ; or if the spasm is 
very much more marked in some one set of muscles ; or if a certain 
set of muscles are paretic or atrophied, or markedly weakened, 
and it is impossible to find any sufficient source of reflex irrita- 
tion, the skull should be opened at the center for motion of the 
affected muscles, and a careful scrutiny made of the outer and 
inner table of the skull, and of the membranes, and if nothing 



EPILEPS2\ 659 

be found In these parts, examine deeper in the brain for 
abnormal conditions. 

If there is a history of cerebritis in early life, and a slow 
mental development, or if the fontanels closed very early, the 
general contour of the skull should be carefully considered 
with reference to uneven or irregular development, or an insuf- 
ficient development and expansion of the cranium, and in the 
absence of other cause for the attacks, a piece of bone may be 
removed for the purpose of allowing expansion, and in this way 
relieve pressure of the brain from a proportionately too small 
calvaria. The habit of operating, however, except in such 
cases as indicated, where there are well-marked evidences for the 
localized lesion, is not to be recommended. 

A full quantitative analysis of the twenty-four hours' urine 
should always be made. A goodly number of cases will be 
found in which there is a marked deficiency in the excretion of 
urea. If this low excretion of urea is regular and continuous 
for some considerable time, and there are no evidences of reflex 
irritation, it is possibly a chronic uremic poisoning, and must 
be treated accordingly. In some subjects, there will be found 
a regular, continuous, low excretion of phosphoric acid, which 
probably indicates deficient oxidation of phosphorus in the sys- 
tem and may excite sufificient irritation to require special 
treatment. 

In the treatment of epilepsy, and of all recurring convulsions, 
moral control is of the greatest importance. The child's life 
should be regulated with the closest attention. Gentle, but 
firm and regular discipline should be constantly preserved. 
There must be a preponderance of quiet, and as much freedom 
from excitement of any kind as possible. The emotional ele- 
ment must not be stimulated ; everything that is likely to 
produce strong emotion of any kind should be avoided and 
guarded against. 

The life should not, however, be idle, but as full of interest 
in objects outside of the child's own personality as is possible, 
without in any way straining the nervous forces. It is often 
very essential that the physician devise ways and means for 
the amusement and occupation of his patient. If there be any 
tendency to any form of immorality, the child should be gently 
led by the strongest influences it is possible to bring to bear, to 
a right kind of thinking. Every person must be studied as an 
individual, in order to know just what line of argument or of 
action will be the most influential, as to just what environments 
will be most potent for good. 

There is no class of cases in which I spend as much time and 
study in the selection of a remedy as in the pure epilepsies. I 



060 THE DISEASES OF CHILDREN. 

know that if I can find the similimum, there is a reasonable 
hope of a cure. My method of study is to select some one 
symptom that is most constant and uniform during the time be- 
tween the attacks, and also one in immediate connection with 
the attack. If possible, I find some symptom that is always 
present, and another that comes with every attack, then look 
for a remedy or remedies having one or both of these symptoms. 
I next look for a remedy or remedies covering any dyscrasia, 
and one covering the general temperament, then for those 
with like aggravations or ameliorations. I make a list of the 
remedies so selected, and opposite each one a tally-mark for 
every symptom common to it and my case. My experience has 
been that I get good results from the higher potencies in these 
pure epilepsies more uniformly than from the low. I continue 
the remedy selected for months, and sometimes for years. In 
the reflex convulsions I use the lower potencies more frequently 
than I do the higher. 

Never forget, under any circumstances, that any and every 
possible source of irritation must be removed as soon as 
possible. 

The entire materia nicdica is the list of remedies from which 
the indicated remedy must be selected. The following are 
among those possibly most frequently found to be indicated : 
Absinthium, atJiusa cyn., agaricus, ammonium carb., amy I 
nitrite, argentum chl., arsenicum alb,, belladonna, bufo, calcarea 
carb., calcarea pJios., camphora, cannabis ind., causticum, cedron, 
chiniii'm ars., cicuta vir., cimicifuga, cuprum acet., cypripediam, 
gelsemium, glonoin, hydrocyanic acid, hyoscyamus, hypericum, 
ignatia, kali brom., kali carb., kalipJws., lachesis, mag7iesiaphos,, 
moschus, nitric acid, nux vom., cenanthe croc, platinum, plum,- 
bum, silicia, stannum, staphisagria, stramonium, sulphur, viscum, 
alb., veratrum album, veratriun viride, and the zincs. 

It would not be right to neglect some attention to the treat- 
ment used in other schools of medicine, and to palliative 
measures. 

There are cases in which it seems absolutely necessary to 
overpower the convulsive attacks, temporarily at least. Per- 
manent cures have resulted from the administration of power- 
ful antispasmodic remedies. 

For many years the bromides have been probably the main 
reliance of the majority of the medical profession. The va- 
rious bromides are used, the particular one being dependent 
usually on the individual preference of the physician in attend- 
ance. Mixtures of bromid and chloral hydrate are often used. 
I do not propose here to discuss the bromid treatment. The 
dose for a child ranges from three to ten grains, repeated from 



EPILEPSr. 661 

three to four times a day. It is better to give it in milk or a 
considerable quantity of water. 

Chloral hydrate may be given to children in from two to five 
grain doses, or a mixture in which each dose shall consist of 
from five to ten grains of one of the bromides, and from two to 
five grains of chloral hydrate. Inhalation of amyl nitrite, a 
few drops on a handkerchief, immediately on the appearance 
of an aura, will often prevent an attack. 



CHAPTER III. 

CHOREA (ST. VITUS' DANCE). 

Definition. — Chorea is an affection of the nervous system of 
uncertain origin, affecting, for the most part, children between 
the ages of six and thirteen, and characterized by erratic, invol- 
untary, and uncontrollable twitchings or jerkings of certain 
muscles, or groups of muscles, which are, however, as a rule, 
quiescent during sleep. 

It may be partial or general — unilateral or bilateral — affect- 
ing only a single group of muscles, or implicating every volun- 
tary muscle in the body. 

It may be sub-acute or chronic, but is usually neither painful 
nor dangerous. The patient is not deprived of either volition 
or consciousness, nor is the disease attended with fever. The 
French call \t folic inusculaire, or '' insanity of the muscles." 

When the spasmodic movements are confined to one side, 
the affection is called Jiemi-chorea; when paralysis is associated 
with it, chorea paralytica; and when the chorea follows a paral- 
ysis, it is called post-paralytic chorea. This last is very similar 
to paralysis agitans. 

Etiology. — There is no fixed or universal cause for chorea. 
In one case the disease may have a central and in another a 
reflex origin. 

It may arise from some organic and incurable disease of the 
brain or spinal cord, or, on the other hand, it may be caused 
by a purely functional derangement of some nerve center or 
peripheral nerve branch. Cases have been recorded, in which 
an immediate cure was effected by the removal of a tape worm, 
or the root of a diseased tooth. 

The disease is so commonly associated with rheumatism that 
the latter is, by some authorities, considered an almost neces- 
sary concomitant of chorea. It is a well-established fact that 
chorea, like rheumatism, is most prevalent in the spring, and 
in damp climates, and that the heart lesions of rheumatism are 
also observed very commonly in the victims of chorea. But, 
on the other hand, there is no constancy in the association of 
the two diseases, and many severe cases of chorea have been 
observed in which there was neither rheumatic nor cardiac 
complications. 
(662) 



CHOREA (ST. VITUS' DANCE). 663 

Girls, whose nervous system is proverbially more impression- 
able than that of boys, are affected with chorea more often 
than the latter — the proportion of victims being generally 
stated as five to two. 

In very many instances, fright has been clearly recognized as 
the exciting cause. Any sudden mental shock or intense emo- 
tion may develop an attack, in a previously healthy child of 
nervous organization. 

The inherent power of imitation is held responsible for those 
occasional epidemics of chorea which have been frequently 
observed in boarding schools, where a number of impression- 
able youth are assembled together. No one has observed any 
special tendency to hereditary transmission of the disease. 

In many cases, the affection so closely resembles hysteria as 
to be indistinguishable from it. 

Among the predisposing causes of chorea are scarlet fever, 
measles, and diphtheria; indeed, any disease which lowers the 
tone of the system, may lead up to an attack of chorea. Girls 
affected with chlorosis, anemia, dysmenorrhea, or amenorrhea, 
are very prone to this affection. Overstudy, bad air, bad food, 
anything, in fact, which interferes with full nutrition, and a 
perfect state of general health, may be regarded as a cause — 
near or remote — of this perverted condition of the nervous 
system. 

Dr. Worcester states that an investigation in regard to its 
occurrence among school children, showed that over twenty per 
cent, of the young children in the public schools of New York 
are troubled with choreic affections of greater or less gravity. 
These varied from slight movements of the hands and twitch- 
ing of the facial muscles to such as attracted the notice of vis- 
itors. In some cases the disturbance of the nervous system 
which causes the outbreak, is not of a mental, but of a reflex 
nature, owing to some peripheral irritation spreading to the 
nerve centers. 

The fact that girls are more often affected just prior to pu- 
berty, or at the time when the organism is undergoing those 
preparative changes which precede menstruation, is strongly 
indicative of the reflex character of the exciting cause, and 
places the affection in the category of reflex neurosis. 

Pathology. — From what has already been said, it is apparent 
that chorea is rather a symptom than a disease /^r.j^; the irreg- 
ular and erratic explosions of nerve force which characterize 
its manifestations may depend upon organic changes in the 
corpus striatum and thalamus, or to hyperemia or anemia 
of nerve centers; or, as maintained by some, the disturbance 
may be due to capillary embolisms. All of these hypotheses 



664 THE DISEASES OF CHILDREN. 

have been discussed, and in the few fatal cases which have been 
investigated, all of them have been found partial verifications. 
But in spite of this, and after all is said, chorea has no morbid 
anatomy ; ^' there is no one lesion of constant standing, save 
the fungi of vegetations which occupy the edges of the aortic 
and mitral valves ; but endocarditis, in the form of vegetations, 
is present in the greater number of cases." 

Goodhart states that, ** Of the fatal cases already recorded 
(thirty in all), these were present in twenty-eight, doubtful in 
one, and absent certainly only once. Their absence is quite 
the exception. The mitral was affected alone fifteen times ; 
both aortic and mitral valves, nine times ; the aortic valves 
alone four times ; and pericarditis occurred with the endocar- 
ditis six times. 

*' The constancy of these little growths upon the edges of the 
valves has led to a very direct, simple, and fascinating pathol- 
ogy for chorea, in the suggestion that it is due to embolism. 
The vegetations are, it is supposed, washed off the valves and 
carried into the smaller branches of the cerebral arteries, and 
thus produce local anemia, malnutrition, and degeneration of the 
cerebral cortex and ganglia, which lead to the loss of control, 
over the muscles." 

This view of the pathology of chorea, while ingenious and 
probably true of many fatal cases, fails to explain that larger 
class of non-fatal cases in which the affection is confined to a 
small group of muscles, and is not only trifling in extent, but 
of limited duration. 

In some of the recorded cases in which these vegetations 
were noticed, there was no audible heart-murmur during life, 
nor other indication of valvular disease, which could hardly be 
the case if this were the true theory of causation. It should be 
remembered, too, that in these fatal cases, we witness the ex- 
treme violence of the choreic manifestations, accompanied with 
delirium, and other symptoms denoting central ganglionic dis- 
turbance — symptoms always absent in those far more numerous 
cases which, from their comparative mildness and brief dura- 
tion, have been designated chorea minor. The clinical differ- 
ences between ordinary chorea and the acute and fatal forms,^ 
are of themselves suggestive of a different pathology, and the 
speedy recovery after delivery in the chorea of pregnancy, or 
(as in several cases on record), after expulsion of intestinal 
worms, is inconsistent with the existence of embolism. Avery 
important consideration in this connection, is the remarkable 
limitation of chorea to the period of childhood — the period be- 
tween infancy and puberty. This is a limitation, as stated by 
Dr. Broadbent, '' if not without parallel, certainly unequalled, 



CHOREA (ST. VITUS' DANCE). 665 

and it points to a condition of nerve centers in childhood 
which specially favors the occurrence of the disease. This 
condition may be said with confidence to be the fact that child- 
hood is the period of special activity of the sensori-motor 
ganglia." 

There seems to be a pretty general agreement that the cor- 
pora striata are involved in the disease, but there are many, 
among whom are Dickinson, Ross, Meynert, and Hughhngs- 
Jackson, who doubt whether chorea is due to any special 
disease of the spinal cord or other part of the nervous system, 
but think that it, like epilepsy, is due to a disturbance of the 
whole of the centers. Dr. Henry P. Stearns, superintendent 
of the Hartford Retreat, says that the primary condition is one 
of instability of nerve functio7i. Such a change has occurred 
in the elemental tissue of the nerve as to injure its power of 
activity so far as it is under the control of the will. The nerve 
has been stimulated to over-activity, or its energy impaired by 
other causes arising within the system itself. Dr. Hughlings- 
Jackson expresses the same idea, when he says that the " cen- 
ters are diseased when half educated," and that the symptoms 
are due to '^ under nutrition " of the tissues affected. 

Symptoms and Course. — The definition of Dr. Sturges, that 
'' Chorea consists in an exaggerated fidgetiness," will serve to 
emphasize the fact that chorea is a disease of varied degree. 
In slight cases, the affection may amount to no more than an 
involuntary but constant winking of one or both eyelids, or the 
twitching of one corner of the mouth. But in severe or well- 
marked cases, the child lies extended in bed, making all sorts 
of grimaces, with its arms stretched out on the countepane, its 
fingers pointing in all directions but the natural one, and the 
forearms and arms so rotated inwards as to make the palms 
look outwards. In mild cases, the child may be perfectly quiet 
when lying down, and for a short time even when sitting or 
standing, if not conscious of being observed ; but when walking 
or while under examination, there will be various fidgety ac- 
tions, such as abrupt flexion of the fingers, a sudden pronation 
of the forearm, or hitching up one shoulder ; or there is a shuf- 
fling of a foot on the floor, a jerk of the head or twitch of the 
mouth or eyelids. If the patient is told to do anything, the 
movements are multiplied in the muscles employed and the 
actions are uncertain and erratic. 

An object will be picked up and held, but the hand is brought 
down upon it hastily and after various random excursions. In 
the severest cases, the contortions, grimaces and jerkings are 
incessant. 

In walking, the gait is slow, shuffling, and uneven, the steps 



666 THE DISEASES OF CHILDREN. 

of unequal length and time, so that the line of progress is devi- 
ating. In these severest cases, every muscle in the body ap- 
pears to be thrown in turn into violent contraction ; the face 
undergoes the most grotesque contortions, the eyes roll to and 
fro, the teeth are snapped or ground together, the whole body 
writhes, and the limbs are in unceasing motion. The patient 
cannot put a cup of drink to his mouth, without a great deal 
of management, and is apt to spill it all over himself or his 
neighbor ; mastication becomes difificult or impossible, and the 
first act of deglutition is impeded. 

There is, generally, muscular rest during sleep, but this is 
by no means constant. In many cases, there is great difficulty 
in falling asleep, owing to continuance of the muscular spasms, 
and sleep, when secured, is not profound, but broken by 
dreams and moans. 

On awaking in the morning, there is at first muscular rest, but 
the spasm soon commences, especially on rising and attempt- 
ing to dress. 

The vocal cords and muscles of the larynx may be affected, 
and as a result, there is a quasi aphonia, so that the speech is 
husky and subdued. In other cases, the voice is shrill and 
squeaky. Speech is nearly always modified. The incoordina- 
tion of the lips and tongue make it difficult to articulate, which 
is quite distressing to both the speaker and the listener, the 
words being ''snapped " and cut short. In some cases, speech 
is quite unintelligible. The patient begins a sentence, but can- 
not finish it because his tongue is in the way ; sometimes he is 
only able to pronounce one syllable at a time. When asked to 
show the tongue, it is thrust out suddenly and as suddenly re- 
tracted. This sudden protrusion and withdrawal of the tongue, 
called the ''choreic thrust," is almost diagnostic of the disor- 
der. In the majority of cases, voluntary motion is not entirely 
abolished, but only impeded by a failure of the coordinating 
power. 

Although the involuntary movements may be incessant, the 
patient, nevertheless, succeeds in executing voluntary move- 
ments. It is true that he performs them in an awkward, 
clumsy, imperfect and roundabout way ; the intended move- 
ment is commenced, but is interrupted by twitchings before it 
can be executed. The patient then begins to maneuver and 
succeeds after a time in accomplishing his purpose ; but at 
other times, the effect of exerting the will seems to be an in- 
crease of the spasm, which, from having been limited to the 
face and hands, may then involve the whole body. Any effort 
on the part of the patient to subdue the spasm and to keep 
his face and limbs quiet, is often sufficient to increase the vio- 



CHOREA {ST. VITUS' DANCE). 667 

lence of the twitches. It is to be remarked that even in ex- 
treme cases, the movements, violent as they may be, are in 
some degree circumscribed ; the arms, for example, are not 
thrown up over the head, nor do the legs go to the full extent 
of their range of motion. The tongue is rarely bitten, although 
the lips may be. 

Chorea is generally gradual in its access, even in those cases 
Avhich eventually become severe. It is very commonly one- 
sided for a time, and occasionally so throughout (hemichorea). 
In nearly all cases, the abnormal movements are more pro- 
nounced on one side than the other, and this is generally the left. 
Mental disturbances are rarely absent, and become more devel- 
oped the longer the disease continues. Most patients are ex- 
tremely irritable ; good-natured persons become passionate ; 
the peaceable quarrelsome ; the intelligent appear childish and 
simple ; the countenance becomes dull and stupid ; there is 
marked inattention, and the memory is impaired. Some pa- 
tients are shy and timid ; all are more or less silly. In some 
cases this amounts to imbecility. These symptoms are not only 
observed toward the end of a prolonged attack, but are often 
present at an early period of the complaint, especially when 
there are tendencies to or complications with hysteria. These 
aberrations of mind are not, however, likely to be permanent, 
but pass away as recovery in general takes place. 

Complications. — We have already spoken of the fact that 
rheumatism is by some good authorities regarded as a factor in 
producing the phenomena of chorea. However this may be, 
the fact stands that the two diseases are frequently associated 
more or less directly, and that rheumatism miay not seldom be 
regarded in the light of at least a complication. Thus, Goodhart 
has compiled a list of one hundred and forty-one cases, of which 
number thirty-nine had had rheumatic fever, and fifty more had 
a history of rheumatism in some of their near relatives. His 
conclusion regarding the association of the two diseases is as 
follows : ''After having gone carefully into the question, I be- 
lieve some thirty per cent, of families, taken indiscriminately, 
are rheumatic, while for chorea the percentage is about sixty." 
There is in some cases such an impairment of motor power in 
the voluntary muscles as to amount to complete paralysis. 
Chorea sometimes succeeds hemiplegia in the paralyzed parts ; 
more rarely chorea deepens into paralysis. Cases again are met 
with, in which with facial hemiplegia there is chorea of the 
limbs of the same side. 

In the violent and fatal forms of chorea there is almost always 
•delirium. Impairment of sensation is not uncommon, and 
hemi-anesthesia is almost always associated with hemichorea. 



668 THE DISEASES OF CHILDREN. 

Hysteria, more or less pronounced, is quite commonly asso- 
ciated with chorea. We have already spoken of the frequency 
with which the heart is involved in even mild cases of the mal- 
ady. In all cases, even the mildest, the heart should receive 
proper attention. 

Prognosis. — There is nearly always — always in cases of periph- 
eral origin — a tendency to spontaneous recovery. 

The disease is rarely fatal in children, and when it is so, the 
case is acute and violent from a very early period of the attack ; 
and it is rare for the malady to run its usual course, and then 
take on a very serious character. Relapses are very common, 
and the oftener they occur the greater danger there is of the 
disease becoming chronic and incurable. The average dura- 
tion of the affection is stated by Broadbent to be about two 
months. If prolonged beyond the third month, it may be ex. 
ceedingly chronic, and go on — now better, now worse — for one 
or two years. When associated with menstrual disorders in girls, 
or occurring before puberty, the prospects for recovery are bet- 
ter than when associated with acute rheumatism, or after 
puberty. 

Diagnosis. — The only maladies which are at all likely to be 
mistaken for chorea are paralysis agitans — which rarely affects 
children — epilepsy, locomotor ataxia, and cerebral and spinal 
schlerosis. A brief study of these affections will suffice to differ- 
entiate them. 

Treatment. — The treatment of chorea, to be successful, must 
take cognizance of the cause and the nature of the ailment as 
affecting the individual case in hand. 

As we have seen, a great variety of causes may operate to 
produce, in a given case, the symptoms of chorea. Each case 
must therefore be individualized, and the treatment adapted to 
its special peculiarities. Where worms are suspected, appropri- 
ate remedies should be given for their expulsion. Girls affected 
with dysmenorrhea or menstrual irregularities, should be given 
remedies suitable for regulating the menstrual function. In all 
cases of chorea the nervous system is more or less unstrung,, 
and the system is morbidly impressionable. For this reason 
the surroundings of the patient should be made favorable to rest 
of body and mind. 

All discussion of the case in the presence of the unfortunate 
victim should be avoided. The child should be taken out of 
school and kept out until cured. 

Light exercise of a rhythmical character is very beneficial. I 
once had a case of chorea that was cured by the use of roller 
skates. Music has great power over these patients, and will 
often have a most soothing and beneficial effect. Dr. Julia 



CHOREA (ST. VITUS' DANCE). 669 

Holmes Smith relates a case of a ballet dancer, who had perfect 
control over her limbs when engaged in dancing, but w^ho, after 
retiring from the stage, w^ould be seized with the most horrible 
contortions. As both plethoric and anemic children are subject 
to chorea, the diet should be adapted to the special nutritive 
needs of the individual. Judicious feeding will be often found 
a powerful adjunct to medicinal treatment. 

In our own experience we have found electricity to be a 
remedy par excellence. We have always used the Faradic cur- 
rent, giving it as strong as could be borne without discomfort. 
Our method of applying it has been to place one pole (indis- 
criminately), over the solar plexus, and slowly pass the other 
up and down the spine, continuing the application for from 
seven to ten miinutes daily. 

Massage is another measure which has seemed to be very 
helpful in many severe cases. 

Among the drugs which have been successfully used in the 
treatment of chorea, arsenic stands preeminent. The patho- 
genesis of arsenic abounds in symptoms simulating all forms of 
nervous diseases. 

Dr. Hammond and other authorities of the Old School give 
the drug in the form of Fowler's Solution, administering it, by 
preference, hypodermatically. It may be administered in this 
manner to a child in doses of from two to five drops, diluted 
with an equal quantity o{ glycerin. In using the hypoderma- 
tic syringe, Hammond says : " The safest location is on the 
front of the forearm, about midway between the wrist and 
elbow. Here the skin is loose and can be easily lifted up by 
the thumb and finger from the tissue below. The arsenic 
should be deposited just under the skin in the cellular tissue, 
and not in the substance of the muscle or skin. The point of 
the syringe should be carried just through the skin and then 
for half an inch parallel to the face of the arm, and the injec- 
tion made slowly." 

In cases complicated with paralysis, strychnia affords an ad- 
mirable remedy. Dr. Hale says that in these cases, he has 
found the arsenite of strychnia 2x of decided value. He also 
gives the following indications for cuprum, which he regards 
highly in certain cases : '* The choreic movements are charac- 
teristic. They appear to start in the fingers and toes and 
spread to the muscles of the limbs. The patients are better 
when lying down, and when asleep, although the sleep is not 
entirely free from choreic movements. The muscles of the 
throat are affected, causing dread of suffocation, and difficult 
deglutition. As taught by Rademacher, under certain circum- 
stances, copper appears to enrich the blood like iron. If your 



670 THE DISEASES OF CHILDREN. 

cases are chlorotic, it is an additional indication for copper. 
If cuprum fails, try the arsenite of copper, which, in my hands^ 
has cured two cases. Tablets of the ix or 2x; one after meals, 
and at bedtime." This same high authority thus speaks of 
cimicifuga: *' It is useful both in ' fright chorea ' and in many 
cases of chorea appearing just before or at puberty in girls. 
Cimicifuga, given freely, will bring on the menses, after which 
the chorea will improve. It will cure chorea in older girls 
when it appears only before and during menses. The active 
principle, cimicifugiii, sometimes called ' macrotin,' is quite as 
efficient and more convenient, for a tablet of the ix, containing 
one-tenth of a grain, is equal to five drops of the tincture." 

Dr. C. L. Gregory, and many other homeopathic physicians, 
have had good success with gelsemium, especially in cases 
where the heart's action is weakened. Special stress is laid on 
the importance of administering a good preparation of the green 
or fresh!}' dried root. 

Veratrum viride is recommended highly in cases of chorea, 
affecting robust girls, having violent attacks, the spasmodic 
movements varying on tetanus and opisthotonos. The heart's 
action is very violent, and perhaps spasmodic. (Dose of the 
tincture, one to five drops every three hours.) 

In a discussion before the American Institute of Homeop- 
athy some years ago. Dr. T. F. Allen stated that he valued 
ciciita very highly in chorea, although it was a remedy not 
often used by others. He gave it in the sixth dilution. 

At the same meeting, Dr. Kershaw spoke of having had 
great success wath valerianate of zinc, which he administered 
in the first to the third trituration. He mentioned several 
cases of severe type which had yielded to this remedy when 
others had failed. 

Tarantula is a remedy which has many advocates, especially 
in cases that tend to recur or become chronic. 

Nux vomica. — This remedy is often required, and is indicated 
in those cases w^hen the child complains of vague flying pains 
about the legs and chest ; also a twitching of the jaws and up- 
per extremities. Other symptoms are a sense of numbness in 
the affected muscles; unsteady gait; the feet drag; move- 
ments renewed by the least touch, but lessened by steady pres- 
sure; impaired appetite ; constipation, despondency ; all the 
symptoms worse in the early hours of the morning. 

Ignatia is useful when the left side is mainly affected; when 
the convulsive twitchings are brought on by fright or grief ; are 
worse after eating; sighing and sobbing, and disposition to be 
alone are also characteristic. 

Calcarea carb. is indicated in chorea connected with denti- 



CHOREA {ST. VITUS' DANCE). 671 

tion, or in leuco-phlegmatic patients ; also when the disorder 
is brought on from fright or onanism ; there are the usual 
twitching of the muscles, trembling, and great weariness. 

HyoscyamiLS and stramonium are favorite and often-indicated 
remedies. In the hyoscyamus case the movements of the head 
are from side to side ; the arms thrown about, the gait totter- 
ing, and the patient is talkative and easily excited to laughter. 
The symptoms calling for stramonium are exceedingly charac- 
teristic ; the convulsive movements have the feature of affect- 
ing the parts of the body crosswise, as, for instance, the left 
arm and the right leg, while the other limbs are unaffected ; or 
the muscles of the head and neck are violently agitated ; or 
the spasms may involve the whole body, compelling the per- 
formance of the most grotesque leaps, motions, and gestures ; 
is full of fears ; handles the genital organs ; weeps and laughs 
alternately. 

Speaking from our own experience, the remedy which has 
seemed to be more generally efficacious than any other is the 
vtono-bromid of campJior in the 2x or 3X trituration. We recall 
three cases in which it was the only remedy given, and in which 
the improvement was immediate and permanent. 

In delicate and anemic girls, every means should be em- 
ployed to enrich the blood and improve the general tone of 
the system. Cod-liver oil and some preparation of iron are of 
unquestionable value in such cases. There is a new prepara- 
tion of cod-liver oil w^hich is quite free from the objectionable 
taste of the crude oil, and of the various emulsions, and v/hich 
we have found very beneficial — " Steam's Wine of Cod-Liver 
Oil." 

This preparation can be given to any one regardless of their 
antipathies, as the taste and smell of the oil are perfectly dis- 
guised. 

The moral treatment of these cases must not be forgotten. 
They must be encouraged and cheered ; over-taxation of mind 
and body must be interdicted ; good food and fresh air, with 
plenty of rest, are essential to their recovery. Dr. Edward 
Blake, of London, regards stammering as a local chorea, and 
reports several cures effected by means of labial gymnastics, 
electricity, and the properly affiliated homeopathic remedy. 



CHAPTER IV. 

INFANTILE TETANUS (TRISMUS NASCENTIUM ; LOCKJAW). 

Definition. — Infantile tetanus is a rare but very fatal form of 
eclampsia occurring occasionally during the first two weeks of 
life, and characterized by more or less general tonic contraction 
of the voluntary muscles ; the spasm beginning, as a rule, in 
the muscles of mastication, from which it extends to those of 
the trunk and limbs, with irregularly recurring exacerbations of 
short duration. 

Causes. — The causes which have been assigned from time to 
time for the production of infantile tetanus are very numerous ; 
the latest theory being that it is propagated and disseminated by 
means of its own peculiar bacillus, and that it is both contagious 
and infectious. As this view of the subject has as much ground 
to support it as any which has preceded it, it will doubtless be 
rigidly maintained until another and more plausible theory 
supplants it. It is a very rare disease among the upper classes 
and the well-to-do, and, in our northern climate, is exceedingly 
rare outside the larger cities. It is more prevalent in the 
extreme south, and more common among the blacks than 
whites. Many physicians having a long and extensive practice 
have probably never seen a case of it ; and yet, in some coun- 
tries, it figures quite formidably in the record of mortuary 
statistics. Dr. J. Lewis Smith says that in New York City it is 
more common than tetanus at any other age, or, indeed, in all 
other ages, ** since the mortuary statistics of this city exhibit 
a larger number of deaths from this disease in the first year of 
life than subsequently." For the year 1892 the health depart- 
ment reports of Chicago show twenty-five deaths from infantile 
tetanus to forty deaths from tetanus among adults. Dr. Smith 
confirms the experience of most other observers who have stud- 
ied the affection, that tetanus is nearly, if not always, found 
among the filthy, ill-fed and depraved residents of the slums. 
It may be said to be always and everywhere associated with 
dirt and ignorance. Dr. Marion Sims and others have endeav- 
ored to prove that one of the most common causes of trismus 
was displacement of the occipital bone from over-riding; others 
have attached great importance to the bad condition of the 
(672) 



INFANTILE TETANUS. 673 

umbilical cord, which in several instances has been found sup- 
purating, or in a state of inflammation. Without entering into 
a discussion of the vexed question, it can be safely stated that 
the cause is not always the same, and that among the most com- 
mon etiological factors in its production are irritation and in- 
flamm.ation of the umbilical cord, injuries to the head or other 
portions of the body during birth, circumcision, cold and 
dampness. 

Any or all of these agencies are capable of producing, in a 
new-born infant, other things being favorable, that train of phe- 
nomena which is called tetanus. 

Symptoms. — Tetanus neonatorum comes on usually between 
the third and eighth day after birth, but occasionally not until 
some days later. Dr. J. L. Smith has tabulated forty cases, in 
which the youngest case was under two days old, the oldest 
twelve days, and nine cases were three days old. Niemeyer 
says — but this is undoubtedly an error — that it never occurs 
except between the first and fifth day after the fall of the navel 
string. Restlessness is generally the first noticeable symptom 
of an attack ; the child cries out in its sleep and seems greatly 
distressed. 

It next refuses to be pacified with the breast, or becomes in- 
capable of taking it. The nipple, if seized, cannot be retained, 
and the milk is regurgitated or dribbles out of the mouth, 
owing to the difficulty of swallowing. On attempting to insert 
the finger into the mouth of the patient, we find that the jaws, 
though not absolutely closed, are more or less fixed. There is 
rigidity of the masseters, and the disease gradually extends to 
the other voluntary muscles, so that in the course of a few 
hours the muscles of the limbs, as well as of the trunk, are in- 
volved. The rigidity of the muscles is progressive, and when 
it has reached its maximum, the jaws are fixed almost immov- 
ably, often with a little interspace between them, through which 
the tongue presses, and in which frothy saliva collects. Stiffen- 
ing of the cervical muscles draws the head backward and holds 
it there; the forearms are flexed ; the thumbs are drawn across 
the palms of the hands and are firmly clenched by the fingers ; 
the great toes are adducted, and the other toes flexed. Occa- 
sionally opisthotonos results from the extreme contraction of 
the dorsal and posterior cervical muscles. 

Frequent exacerbations occur in the muscular contractions, 
sometimes without apparent cause, and sometimes produced 
by anything which excites or disturbs the child. Handling and 
attempts at feeding provoke renewed paroxysms. During the 
paroxysms the eyelids are tightly compressed, as well as the 
hps ; the forehead and cheeks are thrown into wrinkles, and the 
D. C— 43 



674 THE DISEASES OF CHILDREN. 

physiognomy is indicative of great suffering. Breathing is 
much impeded, and in some cases suspended, so that the child 
dies of suffocation. In fatal cases, the paroxysms occur more 
and more frequently until the period of collapse. It is usually 
difficult, if not impossible, to ascertain the condition of the 
pupils, owing to the firm compression of the eyelids. 

In some cases, strabismus has been noticed. During the 
stage of collapse the pupils are usually contracted. Death 
usually supervenes from exhaustion in from a few hours to two 
or three days. 

The mortality is very large. Wallace reports thirty-four cases 
with twenty-nine deaths ; and J. Lewis Smith forty cases, with 
thirty-two deaths. In some epidemics, and in certain localities, 
all the cases are fatal. 

Treatment. — Nearly everything in the materia inedica of all 
schools of medical practice has been tried in these cases ; but 
with very unsatisfactory results. Heroic treatment by means 
of ice bags, copious sweatings and anesthetics, which has been 
resorted to in the tetanic convulsions affecting adults, is, of 
course, not to be thought of in treating the new-born. 

The difficulties of treatment are enhanced by the fact that 
the patient is in most instances unable to swallow, so that the 
administration of medicine by the mouth is impossible. The 
hypodermatic syringe, however, enables us to use such drugs 
as can be employed in a fluid and concentrated form. The drugs 
which seem to have been most useful are strychnia, gelsemium, 
conium, cicuta, and passiflora incarnata. The latter is highly 
lauded by Drs. Lindsay and Phares, of Louisiana, but it has to 
be given in large doses — a teaspoonful at frequent intervals. In 
administering the remedy, care must be taken to procure a 
fresh preparation, as it is subject to deterioration if kept long. 

The main dependence must be in sustaining the strength of 
the patient, who is not only menaced by suffocation, but star- 
vation. Stimulants and nourishment must be given by forced 
feeding, or " gavage," as described on page 6i, the rubber tube 
being inserted through the nose, if the mouth is not available. 
The hot bath, or even the hot pack, may prove serviceable. 



CHAPTER V. 

PARALYSIS. 

This symptom may occur in children from the same causes 
as in adults. If the physician will bear in mind the fact that 
paralysis is not a disease, but simply a symptom of disease, and 
that a diagnosis is not made until the disease or lesion, causing 
this symptom, is discovered, he will save many failures. 

Cerebral Paralysis. — Cerebral paralysis is a loss of vol- 
untary motion from some pathological condition within the 
cranium ; it may be congenital or appear at any age. 

There are recorded a large number of cases of cerebral hem- 
orrhage occurring at birth, especially in conjunction with pro- 
tracted or instrumental labor. In these cases there is usually 
rapid softening and breaking down of cerebral tissue, not infre- 
quently to an extent which leaves quite large cavities in the 
brain ; they are much more common in the motor tract, than 
in other parts. 

Symptoms. — At the onset of any cerebral paralysis, there are 
likely to be present concomitant symptoms, due to shock and 
general molecular change, convulsions, fever, dehrium, coma or 
emesis. Bear in mind that a child is much more susceptible 
to any impressions on nerve structure than an adult. The 
location and extent of the convulsion at the onset are of prac- 
tically no assistance in localization ; they may be confined to 
one member, to one side of the body, or be general, no matter 
where the lesion is located. Convulsions recurring later may 
be of the greatest importance in localization. Febrile disturb- 
ance is usually of a very mild nature, the temperature rarely 
going above ioi° Fahr. 

Delirium is often lacking, and when present is usually mild. 
Somnolence is usually present, and not infrequently pronounced 
coma. Emesis, according to my experience, is quite common, 
but not of a severe character. 

The direct symptoms, that is, those dependent, not on shock, 
but the direct result of the lesion, sometimes termed localizing 
symptoms, are paralysis, contractures, exaggerated tendon 
reflexes, mental alienation or impairment, muscular wasting, 
and impairment of speech and hearing. 

(675) 



C76 THE DISEASES OF CHILDREN. 

The direct symptom, paralysis, may be classed under the 
four groups, hemiplegia, double or bilateral hemiplegia, or di- 
plegia ; paraplegia and monoplegia. Hemiplegia is most com- 
mon previous to the third year; if the face is involved, which is 
not very common, it is confined to the parts below the eye. 
Diplegia is usually congenital, and the result of injury to the 
brain during labor or to fetal troubles. Paraplegia is most fre- 
quently congenital, but occasionally appears in early infancy. 
Monoplegia is much more frequent after the third year. 

Contracture of the paralyzed muscles is almost always pres- 
ent; not a rigid, but a pliable contracture. Light, steady, gentle 
effort by an attendant will overcome the contracture, but the 
limb very soon returns to its original position. The joints are 
usually very pliable, so that the limb can be readily moved in 
any direction by an attendant. 

The tendon reflexes are usually slightly exaggerated. 

The mental condition may be anything, from acute mania to 
a slight aberration, or from a simple arrest of intellection to 
absolute idiocy. 

Muscle wasting is not very pronounced, but is usually pres- 
ent in some degree. It is not an atrophy, but a lack of devel- 
opment as a result of non-use. 

Disorders of speech of every shade occur and are very com- 
mon. 

Derangements of hearing are not very common, but occasion- 
ally occur. 

The electrical reactions are nearly normal. 

The affected limb is apt to have a slightly lower temperature 
and a poor circulation. 

Spastic chorea, athetosis, and post-hemiplegic tremor occa- 
sionally occur. 

Recurrent epileptiform convulsions occur in a large number 
of the cases. They may be either general, which is most fre- 
quent, or they may be well-defined localized convulsions. 

Diag7iosis. — In making a diagnosis, the history from the on- 
set should be very carefully taken in minute details ; not infre- 
quently you will find your only clue to a correct diagnosis in 
the onset and chronology of the case. 

In cerebro-spinal meningitis, sporadic or epidemic, the paral- 
ysis is very rarely bilateral. There is a marked tendency to 
somnolence or coma ; there is a high temperature, almost inva- 
riably marked retraction of the head, and general indications 
of severe illness, such as you will very rarely find in the onset 
of a cerebral paralysis. 

In suppurative meningitis, there are marked remissions of 
symptoms, a fluctuating temperature and pulse, chills, and the 



PARALYSIS. 677 

general accompaniments of sepsis, and there will be a discharge 
of pus from lung, ear, orbit or nasal cavity. 

In anterior polyomyelitis the contraction of muscles, except- 
ing in long-standing cases, is absent; the tendon reflex is ab- 
sent, electrical reaction of the paralyzed muscle is altered, and 
there is true muscular atrophy of a part or all of the paralyzed 
muscles. 

In transverse myelitis there are rectal and vesical compli- 
cations. 

Prognosis. — The gravity of the condition depends on the 
extent of the cerebral lesion as shown by the mental condition, 
the extent and character of the paralysis, the contractures, and 
the condition of the reflexes. 

Multiple Cerebro-Spinal Sclerosis.— 5j/;z^?z7/^.j.- Dis- 
seminated Sclerosis, Insular Sclerosis, Focal Sclerosis, Charcot's 
Sclerosis. The sclerotic patches may be in the brain, in the 
spinal cord, or, as is most frequently the case, in both. The 
condition is very uncommon in children, but occurs with suffi- 
cient frequency to warrant a description. 

Symptoms. — According to Charcot, there are two modes of 
onset : one is sudden ; the tremor, weakness and ataxy date 
from convulsion or an apoplectiform seizure. In the other 
form the onset is slow and insidious ; vertigo, headache, vague 
muscular weakness, with incoordination and tremor, are the 
symptoms first noted. In both modes of onset, occular symp- 
toms, such as third and sixth nerve paresis, optic nerve atrophy, 
and nystagmus, defects of articular speech, mental weakness, 
sensory disturbances, and contractures occur to complete the 
diagnosis. 

In childhood, the first form, or the sudden onset, is much 
the more common. Tremor is always present in cases in chil- 
dren. It may be general, even involving the head, bilateral or 
unilateral. It is a pronounced, coarse tremor, and is intensified 
by voluntary muscular exertion. Ataxy of various degrees and 
forms will be observed in the progress of every case. It may 
be in the upper extremities, shown by an inability to carry 
food to the mouth, or an inability to control the hand in writ- 
ing or other movements requiring fine coordination, and is not 
due to tremor or paralysis. The gait may be staggering or 
like that in posterior spinal sclerosis, or there may be a certain 
rigidity of gait, combined with an inability to place the foot 
where it is desired, except by the aid of vision. 

Very early there is likely to be transient strabismus, dilata- 
tion of the pupils, drooping of the lids ; later, in many cases, 
there will be found optic nerve atrophy. Nystagmus occurs in 



678 THE DISEASES OF CHILDREN. 

about half of the cases. It may be noticed only on horizontal 
or lateral movements of the eye, under excitement, at irregular 
intervals, or constantly. 

Probably the most common disorder of speech is a slow 
articulation, each syllable and word being separate, a true 
scanning speech ; there may be more or less marked tremor in 
speaking, and any grade of indistinctness, from a simple, thick 
articulation to absolute unintelligibility. 

The intellect is usually much impaired and not infrequently 
there is absolute dementia. 

Very early in the case there is usually a peculiarly sharp, 
circumscribed, neuralgic headache ; most frequently frontal. 
More or less headache is often a very persistent symptom. 
Vertigo is quite common. 

Early in the attack, paralysis of the third or sixth nerve, or 
of both, is quite common. As the case progresses, the facial 
muscles, and those of the tongue, lips, and pharynx are occa- 
sionally paralyzed. The extremities are usually paralyzed in 
the later stages. 

The superficial reflexes are not usually affected, except in the 
late stage of the disease. The knee jerk is apt to be exaggerated 
early. In a few cases where the posterior column is especially 
involved, the knee jerk may be diminished or absent. 

Causes. — In regard to the causes of this disease, in by far the 
larger number, none can be determined. There is no doubt 
that heredity is an important element in starting the child with 
a predisposition to nerve trouble. It has followed acute infec- 
tious diseases closely enough to be reasonably attributed to 
them. Injury to brain or spine may be a direct cause. Sudden 
and severe emotional shock has seemed to be the direct cause 
in some instances. 

Diagnosis. — In children there will never be any difficulty in 
differentiating, except between it and Friedreich's ataxy. In 
this disease the tremor is not nearly so common, and when 
present is never confined to efforts at voluntary motion, and is 
more like chorea. The nystagmus is only noticed when the 
eyes are directed to some object. The knee jerk is almost in- 
variably absent or very much reduced ; the intellect is rarely 
affected. 

Prognosis. — This disease may be classed among the incurables. 
The physician sometimes, and the friends usually, will be much 
encouraged from time to time, because of marked temporary 
remissions in the symptoms, and on account of days or weeks 
passing without any noticeable advance. It should not be for- 
gotten that such remissions and times when there is no advance- 
ment belong to the regular course of the disease. A few cases 



CEREBRAL HEMORRHAGE. 679 

have seemed to be arrested for a term of years, whether due to 
treatment I cannot say. Death will almost invariably result 
directly from inability to swallow on account of bulbar paresis, 
from lung complications on account of enervation of these or- 
gans, to inanition, from the loss of trophism, or to some inter- 
current trouble. 

Treat7nent. — As to treatment, if a well-defined heredity or 
acquired syphilitic taint be present potassium iodide should al- 
ways be exhibited. It is my habit to give, if the patient is un- 
der fourteen years of age, from three to five-grain doses in four 
drachms of water four times a day. In all cases where no 
syphilitic taint can be clearly determined, the careful study for 
the indicated remedy, and extending through the entire list, 
is the best that you can do. My own great reliance, and the 
treatment I use in every case, even in a very small child, is 
nerve vibration. 



CEREBRAL HEMORRHAGE, THROMBUS AND EMBOLISM. 

The symptoms and results of these three conditions are so 
similar that they can be better considered together than sepa- 
rate ; the differences essential to correct diagnosis and for treat- 
ment must be carefully noted. They are not as frequent in 
children as in adults, but are very much more frequent than was 
supposed a few years ago. 

Cerebral Hemorrhage is an extravasation of blood of 
any amount, from rupture of one or more blood-vessels within 
the cranium. 

Ca2ises. — It may be caused at birth by a long, protracted 
labor, or by the use of forceps, by traumatism at any time sub- 
sequent to birth, by diseased blood-vessels; miliary tubercles 
are found in a good many cases. Dr. Sachs has called particu- 
lar attention to a degeneration of blood-vessels apparently pe- 
culiar to young people. Anything that causes a very marked 
increase of the blood pressure, either general or intracranial, 
such as paroxysms of whooping cough, straining at stool, sud- 
den and violent exercise, sudden and violent emotion, fright, 
or convulsions may be followed immediately by cerebral hem- 
orrhage. It may be looked for as a possible complication in 
typhoid fever, scarlet fever, small-pox, diphtheria, rheumatism 
and acute miliary tuberculosis. In these cases it may follow 
immediately an initial convulsion, or as is more frequent, appear 
in the latest stage of the disease. Hereditary or acquired syph- 
ilis may be a cause. 



680 THE DISEASES OF CHILDREN. 

Thrombosis is an occlusion of one or more of the cerebral 
vessels from abnormal conditions in the vessels, and the for- 
mation of a clot within the vessel or vessels at the point of 
trouble. 

Causes. — This may be caused by hereditary or acquired 
syphilis, tubercular conditions, or any disease producing degen- 
eration of the blood-vessels. From my own experience and 
reading, I conclude that this disease is exceedingly rare under 
twenty-five years of age. 

Embolism is a plugging of a cerebral blood-vessel by clot or 
other substance carried to the point of trouble, by the blood 
current, from some other part of the body. 

Causes. — Such diseases as bronchitis, pneumonia, diphtheria, 
small-pox, scarlet fever, measles and rheumatism — in short, any 
disease likely to cause fungus formation on the valves or 
thrombus in the pulmonary veins — may be fruitful sources of 
this condition. Hemorrhoids, or wounds in which a clot may 
form> partly within a blood-vessel, may have a portion of the 
clot washed into the blood current and carried by it to a cere- 
bral vessel. Embolism is probably more frequent in young chil- 
dren than hemorrhage, and very much more so than thrombus. 

Symptoms. — If either of these lesions occur at birth, it will 
be difificult to establish evidence of life or regular respiration. 
Nothing further abnormal may be noticed for days or even 
weeks. A hemiplegia or paraplegia, of either the arms or the 
legs, or a monoplegia, may appear very soon, or may not be 
noticed for some weeks. Contractures will appear soon after 
the paralysis. It is very rare for any convulsive seizures to 
appear during the first few months. 

If the lesion occurs subsequent to birth, it may be during 
apparent perfect health, or in the course of the diseases 
mentioned as causes. In nearly every case, there will be loss 
of consciousness, it may be a simple somnolence, or an absolute 
coma. There may or may not be a convulsion. In many cases, 
the head and eyes will be turned in the same direction, and 
that will be toward the side of the lesion. The face is likely to 
be purple, congested ; the breathing labored and often stertor- 
ous. I have had one case, in my experience, in which the face was 
pale. The temperature will rise to from 102° to 104°, or even 
to 107° or 108° Fahr. If it goes above 105°, the case is very 
serious, and death is likely to result. The pulse at first is 
apt to be increased in frequency, but soon becomes slow and full. 
Paralysis may be noticed during the coma, or more frequently 
immediately after the return of consciousness. 

If initiated by a convulsion, the convulsive movements may 



EMBOLISM. 681 

or may not be confined to the muscles which are subsequently 
to become paralyzed. 

The paralyzed muscles may show slight contractions very 
soon. Wasting from non-use, and arrest of development, more 
or less complete in the paralyzed muscles, is always present as 
the case progresses. 

The tendon reflexes will be exaggerated in the paralyzed 
limbs, the electrical reaction will be unchanged until such time 
as degeneration of muscle tissue takes place. The reaction of 
secondary degeneration will not be present even then. Apha- 
sia and mental disturbances are often present. In nearly all 
these cases, associated movements, athetoid movements, or 
chorea-form movements, will supervene sooner or later. The 
paralysis is usually in the form of a hemiplegia. The face may 
or may not be implicated. There are a few cases in which 
there is a paraplegia of either the arms or the legs, and occa- 
sionally a monoplegia. In nearly all cases, a partial recovery 
takes place naturally ; first the leg, then the arm, and lastly, if 
affected at all, the face. This recovery continues to some in- 
definable point and then ceases. The accompanying contrac- 
tures appear early and are persistent ; they are at times so 
severe as to render the limb entirely useless. The flexor and 
adductor muscles are more frequently affected than the exten- 
sor and abductors. Convulsive seizures are quite comm.on 
through the balance of life, although there are a goodly num- 
ber of cases in which they never occur ; they may be general, 
confined to one side, or to a single extremity. 

Diagnosis. — The diagnosis of cerebral paralysis is compara- 
tively easy, but the distinction as to the producing lesion re- 
quires some special attention. In children the presumption is 
in favor of meningeal or cortical lesion, as they are far the most 
common causes of paralysis in children. If the coma be marked 
and prolonged, and there be convulsions occurring very fre- 
quently, it is probably meningeal. If, on the other hand, the 
coma is very slight, of short duration, and there is but one con- 
vulsion, it is probably in the interior of the brain or capsular. 
Early and marked mental defects point to meningeal or corti- 
cal lesion. Hemiplegia without involving the face is cortical. 
If there be convulsive movements m the paralyzed part, it is 
probably cortical. Abnormality or irregularity in the shape of 
the cranium points to cortical lesion. Those cases produced 
by the diseases mentioned as causative, are likely to be intra- 
cranial. 

The differentiation between hemorrhage, thrombus and em- 
bolism, in a large percentage of the cases, is impossible. If there 
be present any condition in which an embolus may exist, and the 



682 THE DISEASES OF CHILDREN. 

initial attack is very sudden, and partial recovery very rapid, it 
is probably embolism. If there is such a condition present as 
to render probable a degeneration of the blood-vessels, and the 
attack is not markedly sudden, and the natural recovery slow, 
it is probably thrombus ; all other cases are probably hemor- 
rhage. It is possible that we may have a condition of circum- 
scribed inflammation and destruction of function in small areas 
of the cortex similar to the condition found in the anterior 
horns in polyomyelitis. I do not know how to distinguish this 
from other lesions. In tumor the headache, vertigo, and pres- 
ence of optic neuritis preceding the attack will enable you to 
differentiate. 

Prognosis. — As to the prognosis in the cases occurring after 
birth, the more profound and long-lasting the coma, the higher 
the temperature, the more imminent is a fatal termination. 
Frequent convulsive attacks are very unfavorable to life. Any 
sign of returning consciousness is favorable, but never fail to call 
attention to a possible relapse speedily into as profound a coma 
as ever. During the coma you may be able to form a very fair 
idea as to the extent of the probable resultant paralysis. When 
consciousness is entirely restored, and the temperature normal or 
nearly so, you can safely predict that the general health will prob- 
ably be restored. You cannot, however, predict what the mental 
condition will be ; this you can only judge of as the weeks go 
by. It is safe to call attention to the fact that there may be 
absolute idiocy ; that the mentality may be arrested at this 
point, that it may be simply retarded in its development, or 
that it may not be affected at all. 

As to the progress of the paralysis, if from a hemorrhage, 
bear in mind that there is very soon formed a clot, the extent 
of which is determined by the extent of the paralysis. This 
clot will soon shrink in size, thus causing an improvement in 
the extent and completeness of the paralysis ; the clot is then 
encysted and begins to degenerate. The contents of the cyst 
finally being entirely absorbed, the walls close together and 
form a cicatrix. During this process gradual improvement in 
the paralysis will take place. If the contractures are marked 
and persistent, there is not only pressure, but irritation present, 
and there is less likelihood of complete recovery. 

The cicatrix is often entirely absorbed, so that an autopsy a 
few years later will fail to reveal any signs of the original hem- 
orrhage. 

While in a certain number of cases there is practically a per- 
fect recovery, in many there has been sufficient permanent 
damage done to the brain tissue to prevent its ever returning to 
a normal functional activity. In these cases a certain amount 



EMBOLISM. 683 

of paralysis, contracture and slowness of development will al- 
ways exist to the end. Always bear in mind that if the initial 
attaclfis indicative of profound cerebral lesion, even if there be 
comparatively little motor disturbance, that it is possible to 
have extensive lesion of the occipital or frontal regions without 
marked paralysis, and in these cases the prognosis respecting 
the m.entality is w^xy unfavorable. 

In thrombus, remember a greater or less portion of the brain 
is cut off from circulation, that there is a tendency to degener- 
ative action, that restoration can only take place through col- 
lateral circulation, that therefore the chances of a complete 
recovery, or of rapid progress, are not nearly so favorable. 
There is more probability that a secondary softening involving 
the areas deprived of circulation will occur. 

In embolism, remember that there is no pressure, that in a cer- 
tain number of cases the force of the circulation will break up the 
plug and carry the particles to destruction, and a complete and 
early recovery take place ; that the blood-vessels and surround- 
ing tissues are, at the onset, in a normal condition, thus allow- 
ing opportunity, except in a case of terminal vessels, for free 
collateral circulation. By this means the area cut off from cir- 
culation is soon, to a greater or less degree, restored to nutri- 
tion and to functional activity, and the prognosis is rendered 
proportionately favorable as to rapidity and completeness 
of recovery. It, however, is never wise in any case to be pro- 
fuse in promises of recovery ; no man knows what change may 
take place in a day to materially alter the patient's prospects. 
In the congenital cases the prognosis is always grave, the 
chances for recovery from the paralysis are very slight, and con- 
vulsions are almost certain to be frequent and severe, and the 
mentality almost certain to be of a very low grade. There are 
exceptions — that is, a few cases have grown up with fair mental- 
ity, and some free from convulsions. 

Treatment. — In regard to the treatment of hemorrhage, 
"thrombus or embolism, in the congenital cases, your first efforts 
will be directed to establishing and maintaining regular respira- 
tion ; this at first must be accomplished by mechanical means, 
such as artificial respiration, inflating the lungs with air, and 
forcing the air out again by compression at regular intervals. 
After self-respiration has been established, lachesis I2x may 
be of benefit in assisting regularity. 

In the cases occurring after birth, the one most important 
thing for the physician to remember is, that he can easily do 
too much; the parents and friends are anxious that something 
be done, and not infrequently has the physician jeopardized 
the prospect of the patient on account of the importunity of 



684 THE DISEASES OF CHILDREN. 

parents and friends. If the onset is a convulsion, the ordinary 
rule to put the child in a hot bath is dangerous ; therefore study 
carefully your case when first called to a child in convlilsions 
for the first time. If the temperature is high, make your arrange- 
ments for the bath, in this way getting every one about busy, 
then look carefully for any evidence of the spasm being local 
instead of general, also for any evidences of paralysis ; note 
carefully the character of the respiration and of the pulse ; if 
satisfied that cerebral hemorrhage or thromibus is present, give 
gelsemium 3x if the child be under one year, or ix if under 
three years, and from one to two drop doses of the tincture if 
over three years of age. Secalc cornutuni may be used in the 
same doses. Lachesis I2x or cuprum aceticum 3X may be 
indicated. None of these may be indicated ; each physician 
must select for himself the indicated remedy in the individual 
case. These are the remedies I believe most frequently needed. 
If unable to control the convulsions with remedies within a 
reasonable time, chloroform by inhalation ought to be used, of 
course with caution. The mixture of bromide and chloral hy- 
drate^ on page 656, may be, in some persistent cases, advisable, 
or small doses of chloral hydrate alone may be used. Hot 
sponging may be of service. 

If the onset is with coma, have the child kept very quiet ; do 
not put ice on or about the head, but occasionally tepid body 
and head sponging should be used, if the temperature does not 
fall within a few hours. If the rectum is loaded, unload it by 
enema ; aconite 3X will, I think, be called for more frequently 
than any other remedy; never, under any circumstances, give 
opium to a child under seven years of age ; if older than seven, 
opium IX or 3X, stramonium 3X, or nux vomica 3X. Keep the 
patient quiet and continue the selected remedy till conscious- 
ness is restored ; continued or rising temperature is of grave 
import. Always look carefully after the urinary excretion ; if 
markedly deficient, helleboris niger ix or 3X will probably be 
the best remedy, although apis^ chainomilla, apocynum, gel- 
semium, sweet spts. nitre, or other remedies may be indicated 
and should be used. After the convulsions or coma are relieved, 
you can do no better than to watch the case carefully until the 
natural amelioration is well established, then commence a line 
of treatment, looking to the prevention of contractures and the 
cure of the paralysis. 

Cerebral Tumors. — Tumors of the brain seem to be as 
frequent in persons under nineteen years of age as in older people; 
they are more frequent in boys than in girls: they may occur 
in any portion of the brain or membranes. The varieties that 



CEREBRAL TUMORS. 685 

have been diagnosticated are gumma, tubercular, carcinoma, 
cysts, sarcoma, glioma and glio-sarcoma. Under this head will 
also be included intracranial aneurism. The most frequent in 
young children is the tubercular. The most common location of 
these is in the cerebellum and on the base. They are very 
apt to be multiple and distributed irregularly over a very 
large area. 

Causes. — The causes of cerebral tumor may be determined 
with reasonable certainty in acute cases, but in the great ma- 
jority, the cause is a mere m.atter of speculation. Heredity, 
undoubtedly, is an important factor in a great many cases ; di- 
rect blows on the head are probably the immediate cause in a 
good many instances. Extension of tumors of the ear, nose, 
orbit and scalp, or even from the pharynx into the brain, is 
occasional. 

Symptoms. — The immediate condition of the cerebral circu- 
lation has a direct and marked effect on the prominence of the 
sym.ptoms ; this is the case in nearly all kinds of tumor, but of 
course, is much more marked, the more vascular the tumor. 
The importance of this fact is that it enables the physician to 
give special direction, in each case, to avoid all those things 
having a tendency to produce sudden changes in the circulation 
of the brain. In a large number of the cases, the earliest symp- 
toms will be, in quite young children, a loss of interest in its 
play and in its surroundings, generally a disposition to lie down 
and keep quiet, w^ith, not infrequently, an irritable, fretful dis- 
position, coupled, in many cases, with somnolence. Occasion- 
ally, there is a marked insanity of a varying degree of intensity, 
or there may be, in the course of the disease, absolute imbe- 
cility. In older children, the mental inactivity also shows 
itself early, but more uniformly in the way of a slow percep- 
tion, comprehension and reasoning. The child becomes 
stupid and dull, and may, at any time, become maniacal or 
melancholic. Late in the case, there is quite frequently such a 
degree of imbecility that the child pays no attention to defe- 
cation or urination whatever, and must be looked after just like 
a young babe. 

In nearly every case, optic neuritis or choked disk will be 
present, more frequently double than unilateral. There may, 
or may not, be associated with it visual defects ; I believe this 
symptom occurs very early in the case ; it has enabled us, on 
occasions, to suggest the beginning of tumor some considerable 
time before there were other symptoms present, sufficient to 
cause suspicion. There is often a general impairment of sight, 
and the field of vision is curtailed in some special direction, or 
may be, in all directions. 



686 THE DISEASES OF CHILDREN. 

Headache is almost universal. It is usually present before 
the tumor is diagnosticated, but is not, I think, as early a symp- 
tom as either of the preceding. It is usually produced or ag- 
gravated by any excitement or undue exertion, that is, by 
anything that causes an increased volume of circulation in the 
brain. It is often intermittent, may be regularly periodical, 
and increases in intensity with the growth of the tumor. It 
may be a dull, heavy, continuous ache, with more or less fre- 
quent exacerbations of great severity. It is usually accompa- 
nied by an indefinable sensation in the head. It is nearly always 
referred, either to the frontal or occipital region ; occasionally, 
though rarely, to a point immediately over the tumor. If there 
be marked tenderness to pressure of the scalp over a circum- 
scribed area, persistent headache in the same location, and the 
headache is aggravated by gentle percussion over the same 
area, there is a strong supposition that the tumor is cortical or 
meningeal. 

General convulsions are very common in the progress of a 
tumor; they may be of any degree, from the slightest twitching 
of the eyes and face, to the severest epileptoid, with pro- 
nounced and prolonged coma. They are apt to appear very 
early in the case. They, at first, occur with long intervals; 
later, are quite apt to come in groups, that is, there will be a 
longer or shorter period between them, and then a large num- 
ber of convulsive seizures a day for a considerable time. It is 
generally understood that these periods mark a rapid growth 
of the tumor or an effusion into the ventricles. Localized con- 
vulsive seizures may occur, depending on the location of the 
tumor, but in a large majority of cases, the convulsions are 
general, no matter where the tumor is located. 

Vomiting is quite apt to occur on any movement of the 
head, after the patient has been confined to the bed some time ; 
it may, or may not, be accompanied by vertigo, and is without 
reference to meals; there may, or may not, be nausea; it is not 
a constant symptom, there being many cases in which it is not 
present. 

Vertigo, if present, is likely to occur at intervals ; the room 
or objects swim around the patient ; there is possibly a sudden 
feeling of losing the balance, as if about to fall, or a feeling of 
nausea and faintness ; the patient will clasp the hand over the 
eyes to shut out the light and surrounding objects. 

Insomnia of various degrees is very often present. Local- 
izing symptoms depend absolutely on the location of the 
tumor in the brain ; they progress gradually, and often irregu- 
larly. 

Localization. — Tumors involving the cortex of the hemi- 



CEREBRAL TUMORS. 687 

Spheres produce mental irregularities, headache, tenderness of 
the scalp, deep-seated and general convulsions. 

If in the frontal lobes, there may be no special localizing 
symptoms; if in the orbital convolutions, there is apt to be 
loss of smell on the side of the lesion. If a case presents con- 
vulsive attacks commencing in one member and spreading to 
others, and is not followed by paralysis, even temporary, there 
is a suspicion of tumor in the frontal convolutions. The third 
frontal convolution will give motor-aphasia, a condition in 
which the comprehension of language is nearly intact, but the 
patient can neither speak nor write words. 

The paracental lobule comprising the anterior and posterior 
border of the fissure of Rolando, the motor centers of the brain, 
will present localizing symptoms clearly defined, and important 
in that they frequently furnish a certain guide to cure through 
operative means. There is likely to be some paresthesia, fol- 
lowed by local spasm, it in turn followed by paralysis. The 
paralysis is at first in most cases a simple weakness, a feeling of 
heaviness ; there is gradual increased loss of power, and finally 
complete paralysis. In many cases, while the progress of the 
paralysis is gradual, it is not regular, but in distinct stages. 
The point at which the initial sensation or spasm begins, prob- 
ably indicates the exact location of the brain lesion ; that is, 
the spasm is apt to begin in the exact muscles for which the 
diseased point is the cortical center. As the tumor spreads, the 
direction of growth may be indicated by the order in the spread 
of the spasm. The paralysis, as the tumor increases in size, 
spreads from one set of muscles to another, till in nearly every 
case (unless death intervenes) of tumor in the motor area, there 
is a complete hemiplegia. A marked paralysis preceding spasm 
is indicative of hemorrhage, an accident occasionally occurring. 

It is impossible to distinguish between a tumor in the cortex 
and one of the white substance immediately beneath the cortex. 

If in the parietal lobes, there is nearly always a disturbance 
of the pain sense, of tactile sensation, of muscle sense, and of 
the sensations of heat and cold. If the tumor be in the inferior 
parietal lobule of the left hemisphere, the patient will not be 
able to recognize printed or written words, can write from dic- 
tation, but not without. 

Tumor in the occipital lobe produces defects in vision; if in the 
right occipital there will be blindness in the left half of both eyes, 
the patient being unable to see anything with either eye to the 
left of a line directly in front of him. If the left occipital be 
the seat of tumor, there may be in addition word blindness. 
Irritation in the occipital lobe gives, in many cases, hallucina- 
tions of light. Frequently recurring hallucinations of light, 



688 THE DISEASES OF CHILDREN. 

followed by more or less marked convulsive action, especially if 
unilateral, and even temporary blindness indicates clearly irri- 
tation in the occipital lobe. If in the tempero-sphenoidal lobe, 
there will probably be present word deafness, a condition in 
which the patient understands language and can talk, but will 
be unable to remember names of persons or things, perfectly 
familiar to him, and consequently is constantly getting wrong 
and incongruous words into his sentences. 

If located in the sylvian fissure, it may produce quite exten- 
sive paralysis, and will produce paraphasia, a condition in which 
the words of a sentence are all mixed up, and the conversation 
is likely to be unintelligible. 

Tumors in the basilar ganglia are exceedingly difficult to 
diagnosticate. Optic neuritis is almost certain to be present. 
Vomiting and vertigo are also frequently present. General 
convulsive attacks are not common. 

Tumors in the pons varolii are likely to produce bilateral 
symptoms ; if in the upper half of the pons, there will be exter- 
nal strabismus from affection of the third and fifth nerve; the 
pupil will be dilated and ptosis present ; ulceration of the cornea 
is quite frequent, and there is likely to be pain, anesthesia and 
tingling of the face. If the tumor be in the lower half of the 
pons, the sixth, seventh, and eighth nerves are the ones impli- 
cated, and we have internal strabismus, contracted pupil and 
deafness, with vertigo ; also paralysis of the face, the patient 
being unable to close the eye. These eye and face symptoms 
are unilateral, with them there is likely to be present paralysis 
and anesthesia of arm and leg, usually not complete ; the eye 
and face symptoms will be on the same side as the lesion, while 
the paralysis and anesthesia of the limbs are on the side oppo- 
site the lesion. 

If located in the medulla oblongata, the glosso-pharyngeal, 
pneumogastric, spinal accessory, and hypo-glossal are the nerves 
affected ; there may be difficulty in swallowing, irregular respira- 
tion, irregular or intermittent pulse, flushing of the skin, pro- 
fuse sweating, polyuria or glycosuria, projectile vomiting, 
retraction of the head, or rolling of the head in the pillow, 
inability to protrude the tongue, to suck, and to articulate; of 
course, it is rare to find all the symptoms present in any one 
case. 

The prominent local symptoms of the cerebellum are vertigo 
and ataxy. The patient is likely to have a feeling of falling or 
turning, always in the same direction ; this is so real as to cause 
him to catch hold of some near object to prevent falling; this 
sensation with vertigo comes in distinct attacks, usually accom- 
panied with very severe headache. There is also a characteristic 



CEREBRAL TUMORS. 689 

ataxic gait, the patient staggers very much as if intoxicated ; 
the body totters from side to side, and the steps are uneven in 
length and character. There is often a tendency to veer to- 
ward the side of the lesion ; the patient does not watch the 
feet as in locomotor ataxy ; there may or may not be paralysis ; 
if present, it will be of the limbs on the side opposite to the 
lesion. Hydrocephalus is a common occurrence in conjunction 
with cerebellar tumor. 

Diagnosis. — The diagnosis as to the character of the tumor 
must be made from general considerations of the characteristics 
of each, and the probable predisposing tendencies in the family, 
or in the patient. 

The main points of distinction from abscess are : Abscess 
often follows suppurative disease of the ear, nose or orbit, and 
caries of the skull. If the result of a blow on the head, abscess 
is likely to develop quickly ; there is fever and altogether a 
picture of rapid, profound trouble ; in abscess, the progress is 
apt to be more rapid at the onset, but there may be an entire 
remission of all symptoms for a long period, and then a sudden, 
severe, fatal return. 

In chronic hydrocephalus, the paralysis will be of the spastic 
variety, will be bilateral and without local spasm. 

Prognosis. — The prognosis is positively unfavorable, except 
in the few cases that can be clearly localized, and are so situated 
as to admit of operation. Death may be sudden from a hem- 
orrhage, or the patient may waste away, finally go into a pro- 
found coma, have frequent convulsions, and die. 

In syphilitic tumors, the prognosis may be much more 
favorable. 

Treatment. — As to the removal of cerebral tumors, if they 
present such symptoms as to be clearly and certainly located 
in the cortex or on the surface of the brain at any point, or in 
the fissures of Rolando or of Sylvius, it is possible to operate, 
provided they are not of such character as to render necessary 
the destruction of too large an area of brain tissue. It will be 
found, however, that a very small percentage present a suffi- 
ciently clear-cut line of symptoms, to make the localization at 
all certain. My practice is never to operate unless the case is 
clear cut. 

The general treatment consists in hygienic and sanitary 
measures ; good full nutrition, the keeping of the circulation, 
especially the portal circulation, in the best possible condition, 
and in directing the avoidance of such things as tend to increase 
the blood pressure in the brain. 

If the tumor be tubercular, cod-liver oil or other fatty nutri- 
ments should be used. 
D. C— 44 



690 THE DISEASES OF CHILDREN. 

In syphilitic tumors, the iodid of potassium has, without 
question, produced a good many cures ; I know of no other 
remedy that has. I do not use the mercurial treatment at all in 
these cases ; I use the iodid of potassium, commencing with 
five grains in a half a drachm of water, three times a day, prefer- 
ably before meals, gradually increasing the size of the dose till, 
in patients over ten years of age, they get from thirty to forty 
grains three times a day. In younger patients, from fifteen to 
twenty-five grains three times a day. If, at any time, the drug 
produces marked disturbance of the stomach, I stop it for a 
week, and give from one to three grain doses of bismuth sub- 
nitrate, and then commence the iodide again, with about one- 
half the last dose, and again increase to the maximum. There 
is no use in exhibiting this drug unless you follow it up per- 
sistently and in large doses. I make no apology for this line 
of treatment. When I learn of any other that can be relied 
upon, I am willing to accept it. 

For the tubercular tumors, calcarea iodid, 3X trituration ; 
calcarea carb. 30c ; diudguaczcjn, ix trituration, have seemed to 
give me good results. I have tried many others, but outside 
of these, have failed to get benefit in any well-marked case of 
cerebral tumor. 

Spinal Paralysis. — Anything that produces pressure or 
destruction of the tissues of the spinal cord may produce paral- 
ysis in the muscles supplied by the cord. The paralysis may 
be in the form of paraplegia, usually of the lower extremities, 
occasionally of the upper, less frequently of both upper and 
lower. One entire limb may be paralyzed, or it may be con- 
fined to an individual muscle or set of muscles ; it is accom- 
panied by atrophy of the paralyzed muscles, and by diminution 
or loss of the tendon reflexes; the superficial or cutaneous 
reflexes are also usually interfered with ; in many cases, cuta- 
neous sensation is diminished or destroyed ; the urinary and 
rectal reflexes are frequently interfered with. The extent of 
the paralysis and the sensory symptoms are directly dependent 
on the location, character, and extent of the lesion in the cord. 

Fracture or dislocation of the spinal column in such a way as 
to compress the cord in its entire transverse section at any 
point, will produce complete bilateral paralysis of both motion 
and sensation of all muscles below the point of injury. If high 
enough up in the column, will produce paralysis of the muscles 
of respiration and heart, causing instant death. 

There may be fracture of the spinous processes, or of the 
arch of the vertebrae in such a manner as to lacerate or impinge 
on a single trace, or a portion only of the transverse section ; in 



SPINAL PARALYSIS. 691 

these cases the symptoms will depend on the exact location 
and extent of the cord lesion. 

Diagnosis. — The diagnosis is made from the history of an in- 
jury of such nature as to render fracture or dislocation prob- 
able or possible, and the presence of motor and sensory symp- 
toms referable to lesion of the cord. 

Treatment. — The treatment in these cases must depend in a 
great measure on the judgment of the attending physician; the 
patient may be put to bed on an air or water mattress, mechan- 
ical appliance used to hold the column firmly in position, an 
operation may be performed, cutting down on to the vertebra, 
and either removing or replacing the misplaced bone. For the 
details of the treatment you will go to your works on surgery. 

I have seen several cases where I am fully convinced there 
had been, by a sudden jerk, a dislocation producing injury to 
the cord, and where the dislocation was only for a few seconds, 
it being immediately reset, either by muscular reaction or the 
peculiarities of the accident, leaving the evidences of the cord 
lesion. 

In examining a case of spinal paralysis, note with care the 
condition of coordination, the tone of the muscles, the condition 
of the reflexes, tendon and superficial, the muscular sense, the 
electrical reaction of the muscles, the trophic condition of the 
muscles, or of a paralyzed limb, the degree and exact distribu- 
tion of the paralysis. 

The localizing of lesions in the cord will be materially facili- 
tated by quoting from Bramwell the functions of the spinal 
nerve roots : 

Fourth Cervical. — Flexion of the forearm, with supination 
and extension of the wrist and fingers, the upper arm raised 
upwards and backwards. 

Fifth Cervical. — Movement of the hand towards the mouth, 
viz., raising the upper arm inwards, flexion of the forearm, with 
supination and extension of the wrist and fingers. 

Sixth Cervical. — The movement of attention, viz., adduction 
and retraction of the upper arm, extension of forearm, pronation 
towards the pubes. 

Seventh Cervical. — The spinctu ani action, viz., adduction 
and rotation inward, and retraction of the upper arm, extension 
of the forearm and flexion of the wrist and fingers so as to bring 
the tips against the flank. 

Eighth Cervical. — Closure of the fist with pronation by ulnar 
flexion of wrist, retraction of the arm with extension of the 
forearm. 

First Dorsal. — Action of the intrinsic muscles of the hand, 
muscles of ball of thumb, interossei, etc. 



G92 THE DISEASES OF CHILDREN. 

Functions of the nerve roots of the lumbar enlarg'ement 
(according to Professors Ferrier and Yeo, from observations 
inade on monkeys; and MM. Paul, Bert, and Marcacci, from 
observations made on cats and dogs) : 

First Lumbar. — Determines contraction of the sartorius, rec- 
tus, and psoas, which flex the hip upon the trunk. (P., B. 
and M.) 

Second Lujnbar. — Excites contraction of the anterior portion 
of the vastus externus, a part of the tensor of the fascia lata, 
and the vastus internus — viz.: the muscles which extend the 
leg or the thigh. (P., B. and M.) 

Third Lumbar. — Similar to that of the second, with some 
differences in detail. It excites part of the vastus externus 
and the anterior part of the biceps, which is an extensor, while 
the posterior portion is a flexor. 

According to Ferrier and Yeo, stimulation of the third lum- 
bar in the monkey causes flexion of the thigh and extension of 
the leg. 

Fourth Lumbar, according to MM. Paul and Marcacci, 
causes, in the cat and dog, movements in the posterior part of 
the biceps, the semi-tendinosus, and the semi-membranosus 
(flexes of the leg or the thigh), the second and third adductions 
of the thigh and the extensors of the thigh. It thus inner- 
vates three kinds of movements, which are in no respect op- 
posed or contradictory. 

According to Professors Ferrier and Yeo, irritation of the 
fourth root, in the monkey, causes extension of the thigh, 
extension of the leg, and pointing of the great toe. 

Fifth Root. — MM. Bert and Marcacci find that, in the dog 
and cat, the fifth root presides over the movements of the tail. 

According to Ferrier and Yeo, irritation of the fifth root in 
the monkey, produces outward rotation of the thigh, flexion 
and inward rotation of the leg, plantar flexion of the foot, and 
flexion of the distal phalanges. 

First Sacral. — Flexion of the leg, plantar flexion of the foot, 
flexion of all the toes at the proximal phalanges, and also of 
the distal phalanx of the hallux. (F. and Y.) 

Second Sacral. — Action of the intrinsic muscles of the foot, 
viz.: adduction and flexion of the hallux, with flexion of 
the proximal phalanges and extension of the distal. (F. 
and Y.) 

In any case, having determined what movements can be per- 
formed and what group or groups of muscles are paralyzed, you 
will, by reference to the functions quoted above, be able to 
locate the segment or segments of the cord, in which the lesion 
is to be found. 



ACUTE IDIOPATHIC MYELITIS. 693 

Potts' Disease. — Potts' disease of the spine is, not infre- 
quently, a cause of a paraplegia. In these cases, it is a result 
of an extension of inflammation from the bone to the mem- 
brane, and to the cord, or of pressure on the root nerves of the 
cord, from displacement of the vertebrae. In some cases, there 
may be a discharge of pus within the canal, producing pres- 
sure, and in a few instances, a hemorrhage is caused in the 
canal, producing pressure. 

A more or less regular elevation of temperature, increase in 
the rapidity of the pulse, tenderness over one or more spinous 
processes, or an irregularity in the prominence of one or more 
of the spinous processes, and the characteristic rigidity of the 
body, point to a Potts' disease. 

For the points of diagnosis and the treatment, refer to 
your works on surgery. The object in mentioning it here is, 
that this cause of paraplegia shall not be, as it so often is, 
overlooked. In many cases of paraplegia from this cause, the 
paralysis has been instantly cured by extension and fixation of 
the spine. 

MYELITIS. 

Myelitis or inflammation of the spinal cord may result from 
caries of the vertebrae, from other forms of traumatism, from 
extension of meningeal inflammation, from extension inward of 
neuritis, or by transmission of irritation over a nerve trunk 
from a distant point, or from the genital organs or the rectum. 
It may be idiopathic, or may be caused by exposure to cold and 
dampness. 

Acute Idiopathic Myelitis.— 5j/;;///^w^.— Is usually ush- 
ered in with a chill followed by a high fever, severe pain in the 
back and also in the abdomen, rigidity of the muscles of the 
abdomen, retention of urine, sharp lancinating pains running 
along the course of the spinal nerves, emerging from the seat of 
inflammation, and paralysis of motion and sensation in both 
legs. 

The pain in the back is increased by the application of heat 
over the spine, apt to be relieved by hot applications over the 
abdomen. The urine soon becomes alkaline and must be drawn 
with a catheter, as there is great liability to a secondary cys- 
titis. The inflammation is prone to extend lengthwise of the 
cord very rapidly. If termination is not speedily fatal, the 
high fever is likely to continue from one to two weeks, subsid- 
ing gradually, and leaving the patient with a chronic myelitis 
and the accompanying paraplegia. A complete cure is possible, 
leaving no sequela. 



694 THE DISEASES OF CHILDREN. 

Treat7nent, — The treatment during the acute stage must be 
conducted with promptness and vigor, great care must be used 
to prevent bed-sores, which are very Hable to occur ; keep the 
patient in a semi-recumbent position, cold appHcations over the 
spine continuously. In the sev^erest cases, the spinal ice-bag may 
be advisable. 

The galvanic current should be applied downward over the 
spine, using from ten to twelve milleamperes ; each application 
should be about five minutes; repeat the application every hour 
or two, depending on the severity of the case. 

My favorite remedies at the onset 2.x^ gelsemium, ej'got, aco- 
nite. If I find that the disease is extending upwards toward the 
upper dorsal and cervical region, and (bear in mind it may extend 
the entire length of the cord in a few hours), the respiration be- 
gins to be affected, and there seems to be no chance of arresting 
its progress, I put on a Spanish-fly plaster, and draw a blister 
about one inch wide along each side of the spinous processes 
along the affected region. A girdle feeling around the body, 
or, if the patient be unable to describe it, you will be able to 
detect it, as the upper border of abdominal muscle tension 
marks the upper border of inflammation. This may not be 
good practice ; there maybe better and surer ways to arrest the 
progress and diminish the inflammation, but as time in these 
cases is very precious ; as an hour even may determine unalter- 
ably the result — and I know of no more speedy methods of 
nearly equal efficacy, I use and advise it. 

If at the onset I find a temperature of 104° Fahr., or higher, 
with a very rapid, full, unyielding, hard pulse, I invariably give 
tincture of veratrum viridc, in from one to four drop doses, 
depending on the age of the child. I give it in water, repeat 
the dose every fifteen minutes to half an hour, remain by the 
bedside, and keep my finger on the pulse until it becomes soft 
and does not exceed from 70 to 80 per minute. I am so par- 
ticular in this that I never, under any circumstances, leave the 
bedside until time to stop the veratrum. 

When all evidence of progression has ceased, attention should 
be given to the reduction of acute inflammation as speedily as 
possible. If the acute inflammation can be arrested before any 
destructive process in the cord has commenced, we will have, 
very soon, a subsidence of the paralysis, and a gradual return 
of both sensation and motion in the legs. There may be left 
irregularities in the heart action, and a form of paralysis be- 
longing to the spastic variety, in which there is an inclination 
of the limb to remain in any position in which it may be placed, 
or there may be a simple spastic paraplegia, or a flaccid form of 
paralysis. 



CHRONIC MYELITIS. 695 

The remedies most likely to be of use after the inflammation 
begins to subside, as shown by lowering of the temperature 
and lessening of the pulse, are : aconite 3x, gelsemium tincture, 
cimicifiiga tincture, physostigma 3x, manganese 3X, oxalic acid 
3x, can7iabis ind. 3X, and kali tod. 3X, given according to their 
special indications. The galvanic current can, with advantage, 
be continued right through the entire course of the disease. 
After progress is arrested, it may be given about twice a day, 
till the temperature and the pulse are nearly normal, then once 
a day — the method and strength as indicated for onset. 

Prognosis. — It is always well, as soon as the nature of the 
case is determined, to say to the parents or friends, that it is a 
case in which you cannot promise to save the life, and, that 
the chances are, that there will be a long-continued or perma- 
nent paralysis of both legs ; also that there is danger of a 
cystitis. 

Chronic Myelitis. — If the paraplegia, following acute my- 
elitis, does not disappear within a very few weeks, we have a 
chronic myelitis. The chronic myelitis frequently occurs with- 
out being preceded by any acute attack ; it may be produced 
as a result of congenital or acquired syphilis, may be tubercu- 
lar, or from other sources previously mentioned as causes of 
myelitis. 

It is impossible, as a rule, to determine the points essential 
to differentiation of the various forms of chronic myelitis in 
children. I shall simply, therefore, outline the general symp- 
toms. 

Symptoms. — It usually comes on very gradually ; there is 
likely to be first noticed a weakness of the legs. The child is 
apt to complain of funny feelings, sometimes of sharp pain in 
different parts of the legs, or occasionally a feeling as if the 
legs were asleep. From older children, we are usually able to 
get a fairly correct idea of the kind of sensation, but in most 
instances, we are unable to get anything definite as to anesthe- 
sia, hyperesthesia, or band sensation. We can only obtain 
information as to the motor symptoms we can observe. There 
will usually be difficulty in emptying the bladder and obstinate 
constipation ; the motor weakness increases until there is abso- 
lute paralysis of both legs, and also of the vescical and anal 
sphincters. 

The trophic conditions of the paralyzed muscles, the condi- 
tion of the tendon and cutaneous reflexes, as well as the pecul- 
iarity of all the symptoms, necessarily depend on the exact 
location and extent of the lesion. 

The paraplegia is more often of the flaccid character, accom- 



696 THE DISEASES OF CHILDREN. 

panied by lowered cutaneous sensations or anesthesia, and 
atrophy of the paralyzed muscles ; but in some cases, there will 
be a spastic paraplegia, with cutaneous hyperesthesia, and with- 
out any atrophy. If the paralysis becomes complete, and the 
patient is bedridden, bed sores are very likely to occur. 

There is, at all times, danger of cystitis from retained urine, 
and of extension of inflammation from the bladder to the kid- 
neys. Respiratory and heart complications are quite common. 

Diagnosis. — The lesions from which chronic myelitis is to be 
distinguished in children, are primary lateral sclerosis, Potts* 
disease and functional paraplegia. 

Prognosis. — A cure can hardly be promised, but a hope of 
arrest, and even of improvement, may be entertained. Cures 
are reported by others, and have occurred in my own practice. 

Treatment. — My treatment consists in spinal extension, elec- 
tricity, dry cupping over the spine, nerve vibration, massage 
and remedies. The remedies I use are : manganese 3x, ergot 
(Squibb's fl. ext.), in from three to ten-drop doses, three or four 
times a day ; cannabis ind. 30c, argcntum chloride, 3X tritura- 
tion, oxalic acid, 3X trituration, calabar bean, 3X and 30c, the 
various j^//j" of potash in the 3X to the I2x triturations, and 
strychnia 30c, according to indications. I have never been 
able to see any results from the administration of mercury in 
any of these cases, even when of syphilitic origin. 

Electricity : I use the galvanic current, apply a downward 
current of from five to ten milleamperes, daily. 

Spinal extension : I use Sayers' apparatus, with neck and arm 
supports, raise the patient so that the feet just clear the floor, 
daily. The first three or four days for fifteen seconds, increase 
the time of suspension gradually until it is about ninety seconds. 

Dry cupping is used directly over the affected portion of the 
spine daily ; allow the cups to remain from five to fifteen min- 
utes. The surface, for some time after the removal of the cups, 
is likely to be discolored quite markedly. In cases where there 
is atrophy and a low circulation in the legs, the vacuum boot 
is often of great service. 

Nerve vibration is to be applied daily, over each spinous 
process, for about ten seconds, as nearly as possible at the same 
time of day ; commence at the cervical region and go down the 
spine. 

Anterior Polyomyelitis, more commonly known as In- 
fantile Spinal Paralysis, is a focal, localized or circumscribed 
myelitis. The lesion is confined to the anterior cornua of one 
segment usually, but three or four segments maybe implicated. 
In most cases, there is but one focus of inflammation in a 



ANTERIOR POLl'OMTELITIS. 697 

segment, but in a few cases, both anterior horns are affected ; 
then again, there may be two or three distinct foci in different 
and separated segments of the cord. 

Causes. — In a great majority of the cases, no cause can be 
assigned. The neuropathic heredity, exposure to damp and 
cold, injury and reflex irritation are the most common assigna- 
ble causes. 

Symptoms. — We recognize a form that seems to be func- 
tional and is entirely dependent on reflex irritation ; it usually 
appears in conjunction with teething, or as a result of genital 
irritation. In these cases the onset is quite frequently accom- 
panied with some febrile disturbance, or a mild convulsion, or 
irritability. It is noticed suddenly that the child does not 
move a leg or an arm ; that when you take hold of the mem- 
ber, it is limp, and offers no resistance to being moved in any 
direction. 

When called to a case of this kind, you will note the absence 
of any indications of cerebral disturbance ; that there is no tend- 
ency to contracture or to resistance. Examine as to the con- 
dition of the gums, also as to the condition of prepuce or 
clitoris. If you find any sufficient cause for reflex irritation, 
there is a reasonable chance that, in a few days, motion will 
begin to return to the, paralyzed member, that no atrophy will 
take place, and that, in a few weeks, the child will be perfectly 
sound. It is probable that in these cases, there is sufificient 
local congestion in certain anterior cornua to prevent function, 
but no inflammation to produce destruction. Of course, any 
source of reflex irritation should be removed at once. 

The onset of true polyomyelitis is usually sudden, is most 
frequent between the second and ninth year, although no age 
is absolutely exempt. The child goes to bed apparently in 
perfect health; in the morning it is found that one foot, one 
leg below the knee, the thigh, or the entire leg and foot, or a 
hand, forearm, upper arm, or the entire arm and hand, or it 
may be some part of one leg and of the arm on the same or 
opposite side, or, exceedingly rarely, both arms or both legs, 
hang perfectly limp and flaccid. The paralyzed part offers no 
resistance to movement in any direction ; the superficial and 
tendon reflexes are very much diminished or entirely absent ; 
the part is apt to be colder than the adjacent parts. 

In by far the greater number of cases, the child feels well, 
and there is no febrile disturbance, or other evidence of sick- 
ness. In a fair minority of cases, there will be, for a few days 
preceding, or the first few days of the attack, mild febrile dis- 
turbance and irritability ; occasionally the attack is ushered in 
by a distinct convulsion. I have never seen a case of polyo- 



698 THE DISEASES OF CHILDREN. 

myelitis commence with, or accompanied by, high temperature, 
except when occurring in the course of some acute disease. 

In a few days, there will be some improvement in the extent 
of the paralysis ; that is, some of the muscles that are paralyzed 
at the onset, regain the power of motion. After the first few 
days, the paralysis remains stationary; there is no tendency to 
extension from one part of the cord to another. Very soon 
the paralyzed muscles begin to atrophy; this process continues 
for some considerable time, and then remains stationary. Aft- 
er a time, contracture in the muscles opposed to those para- 
lyzed begins to appear ; for instance, if flexor muscles are para- 
lyzed, the extensors opposed to those flexors will begin to 
shorten and become contracted ; this contracture is due, in a 
great measure, to the position in which the member is almost 
constantly kept. From these contractures in these cases, a 
large percentage of the various forms of acquired talipes and 
other deformities result. The paralyzed portion, after the first 
week or so, is always colder than the adjacent part ; there are 
no marked sensory disturbances. 

Diagnosis. — This is so distinctly a focal lesion that we often 
find the paralysis restricted to one set of muscles. There is 
very little doubt as to the diagnosis, after the paralysis appears. 
In those cases where there is febrile disturbance preceding the 
attack, polyomyelitis will almost never be thought of until the 
occurrence of the paralysis. 

The absence of any evidence of cerebral disturbance, the 
sudden onset of the complete paralysis, confined to individual 
or contiguous groups of muscles, without sensory symptoms, 
fully determines the nature of the case. The bladder and rec- 
tal functions are never permanently interfered with ; they may 
be for three or four days. 

Prognosis. — This disease, except in the few cases I have des- 
ignated as functional, never tends to recovery. It does not in- 
terfere in any way with the general health. The bone develop- 
ment in the paralyzed member is apt to be retarded. No 
function of the body outside the affected part seems to suffer 
in the least, except in very rare cases, right at the onset ; there 
is no fear of a fatal termination. The child will grow up unable 
to use the certain set of muscles and with some deformity. I 
must be excused for occupying a little extra space here. The 
parents will be told that the child will outgrow the trouble — to 
rub the muscles, to procure a battery and use electricity, to go 
to different baths, and a variety of things. The parents them- 
selves will go from one doctor to another, looking for those who 
will promise a cure in the shortest time. The lack of interest, 
the inclination to avoid painstaking details, and the feeHng of 



ANTERIOR POLl'OMl'ELITIS. 699 

not wanting to bother, on the part of the doctor, combined 
with impatience, and sometimes, also, lack of interest, the 
want of confidence in doctors, and the desire to have the job 
done as cheaply as possible, on the part of the parent, are 
directly chargeable with more deformities than the disease itself. 

It is my uniform habit to say to the parent : '* This case, if it 
is to be cured, must be under a systematic line of treatment, 
directed by one competent physician, who is willing to take the 
time and bother for a period of from three to five or six years. 
The treatment will, of necessity, be expensive, and you will be 
importuned and exhorted to try a hundred other things ; you 
will, time and again, get discouraged because improvement is 
so slow ; but on this line is a possible cure, and on the other, 
that of changing from one to another frequently, there is no 
possibility of a cure." 

In my own experience the results have averaged better with 
the cases coming to my clinics, than in private practice, owing 
to the fact, I am sure, that they will stick to a line of treat- 
ment, while in the wealthier families there is a constant tendency 
to change. 

Treatment. — Always examine the eyes, for refractive trou- 
bles and heterophorea ; the nasal passage, the throat, the gums, 
the chest and the abdomen, the genitals and the rectum. Re- 
move any possible source of irritation at once. As to remedies, 
I have never been able to see any results from their adminis- 
tration internally, except in those of tubercular, strumous and 
syphilitic origin. 

In the tubercular, guactim is, I believe, indicated in a large 
percentage of them, and I am satisfied that I have seen posi- 
tive results from its use. I have found marked indications for 
other remedies in a few cases, and had good results follow their 
administration. 

In strumous cases, the remedy must be carefully selected, 
on the line of totality, and almost any remedy may be found 
to be indicated. 

In the syphilitic cases, kali iod. is as yet my chief remedy. I 
begin with the 3X, and if no results are apparent in two weeks, 
I give the 2x, and in some cases, not many, have found that I 
did not obtain results till I had increased the dose to five grains 
three or four times a day. 

The general nutrition must be carefully attended to. Keep 
the child well nourished ; good air and plenty of it is impor- 
tant ; keep the patient out doors as much as possible. 

Use mechanical appliances to overcome the deformities; do 
not operate for talipes until the paralyzed muscles have com- 
menced to respond to the will. 



700 THE DISEASES OF CHILDREN. 

Electricity I have not found of any avail in removing the 
lesion in the cornua. It is of great service in the treatment of 
the paralyzed muscles. 

Hot baths, regular daily massage, inunctions of various 
kinds, passive exercise, and nerve vibration comprises the line 
of treatment. 

Nerve vibration has seemed to do more toward restoring 
function to the anterior cornu, than any other one thing. I 
apply it daily for some weeks, then rest from it entirely for 
three or four weeks. It should always be used daily, when 
used at all. The effect is better when used in periods, with 
periods of cessation. It should be continued throughout the 
entire treatment. Apply the hammer over the root nerves of 
the diseased cornu, also over the spinous process, also over the 
motor nerve point of the paralyzed muscles. Apply at as 
near the same time each day as possible, and in the same or- 
der from point to point ; hold the hammer on each point about 
two minutes. 

Beside the general hot baths, I have a bucket made suffi- 
ciently large for the foot to stand flat on the bottom, and high 
enough to immerse the entire leg, if the paralysis is in the leg; 
fill this with water at ioo° Fahr., have the patient stand with 
the paralyzed leg in this, then slowly pour in hot water, taking 
pains not to have it strike the leg, until the temperature of the 
water is 103° Fahr., keep it at this point ten minutes. In case 
it is the arm that is paralyzed, have a vessel made of proper 
dimensions for the arm and use it in the same way. I fre- 
quently give this kind of a local bath twice a day, following it 
with brisk rubbing with a coarse towel. 

Other points in the treatment will be found under the gen- 
eral treatment of paralysis. 

Spinal Hemorrhage is occasionally found in the new-born, 
usually in the membrane ; the paralysis is of the flaccid variety, 
and there is a tendency to spontaneous recovery from absorp- 
tion of the clot. In a few cases, on account of the pressure 
and non-absorption of the clot, a secondary descending degen- 
eration follows. The diagnosis is made by the distribution of 
the paralysis and the absence of cerebral symptoms. 

Sympto7ns. — The sudden onset of a paraplegia, accompanied 
with evidence of pain, and, if the child be old enough to ex- 
plain its sensations, a girdle feeling about the body, indicates 
a hemorrhage in the cord or membranes. There will be par- 
esthesias, the tendon reflexes will be diminished or absent, the 
cutaneous reflexes diminished or lost. 

Prognosis. — There will be in most cases a partial recovery very 



PRIMA RT LA TERA L S CLER OS IS. 701 

soon, and often a nearly complete spontaneous recovery in a 
few weeks, that is, unless the hemorrhage occurs in conjunction 
with some chronic disease of the spinal column, or of the cord 
or membranes ; even in these cases there is likely to be a par- 
tial recovery, 

Treatment. — The treatment consists in quiet, the best sanitary 
and hygienic surroundings, and attention to the special nutri- 
tion of the paralyzed muscles. The remedies that I have used 
and that have seemed to be of value are : Acovite 30c, and 
■arnica 30c. 

Primary Lateral Sclerosis is known also as Spasmiodic 
Spinal Paralysis and as Spastic Paraplegia. 

It seems sometimes to be congenital, and often appears be- 
fore the third year, but may appear at any age. The causes 
have never been determined, so far as I am aware. 

Symptoms. — In a large majority of the cases the first symptoms 
appear in infancy. The first thing that is noticed is that the 
child's legs appear stiff ; when lying down it will move them 
about, but is unable to stand on them. The child learns to 
walk very tardily, and is not firm on its feet ; any attempt to 
use the legs increases the stifTness. The legs slowly but grad- 
ually becom.e weaker and weaker, until they become useless. 
Now, in attempting to stand, the legs become rigid, the balls of 
the feet rest on the ground, but the heels are raised up, the toes 
are inclined to cross each other ; the feet and legs, too, become 
crossed ; there is no pain and no fever ; the joints immediately 
appear stiffened if handled ; there is no tremor. If a joint be 
forcibly bent — for instance, the leg flexed on the thigh, which 
causes no pain — it will immediately straighten out as though 
worked by a spring. There are rarely any trophic disturbances. 
The tendon reflexes are exaggerated. The rectal and bladder 
sphincters remain intact. The rigidity remains during sleep. 
The rigidity and inability to control or coordinate movements, 
and all symptoms increase steadily and slowly to a point, then 
remain stationary. This disease does not tend to death. 

The mind in many cases is as bright and clear as in other 
persons of the same age. In a few instances there is a lowered 
grade of mentality, but I believe not due to the disease, but to 
concomitant trouble. 

Treatmeiit. — The only treatment that promises anything, so 
far as I know, is cold to the spine and legs, nerve vibration and 
spinal extension. 

I apply cold douches to the spine and legs daily, observing 
with care that the patient does not remain chilled for any 
length of time following. Apply spinal extension by means of 



702 THE DISEASES OF CHILDREN. 

Sayer's apparatus on alternate days, keeping the patient sus- 
pended from fifteen to sixty seconds ; nerve vibration, by ap- 
plying the hammer over all the spinous processes and the nerve 
roots on each side of the spine, daily, a half minute at each point* 

Hypertrophic Paralysis, Pseudo. — This is a rare disease 
in this country, but is met with occasionally. It commences 
in early life, usually before the second year, but occasionally 
not until the second or ninth year. It runs a slow, steady 
course of from ten to twelve years commonly. Death is most 
frequently the result of implication of the respiratory muscles; 
the immediate cause is quite frequently some form of bronchitis. 

Symptoms. — The earliest symptoms are weakness of the legs, 
soon accompanied with a tendency, when standing, to spread 
the feet far apart ; later to throw the shoulders backward, curv- 
ing the spine backward very markedly. This is an effort to 
keep the center of gravity of the body back of the point at 
which the feet touch the ground ; this is essential, in order to 
preserve the equilibrium. In rising from a sitting posture or 
from stooping, the patient puts his hands on the knees to assist 
in raising the trunk. In an advanced stage, the patient can 
only raise himself from a lying position by first, with the face 
downward, raising himself on his hands spread wide apart, then 
slowly drawing one foot at a time forward, kept wide apart, till 
the feet and hands are fairly close together (the patient in this 
position is on all fours, that is, both feet and both hands are 
on the floor and the arms and legs straight); then, by putting 
first one, then the other, hand on the knee and raising the 
trunk, by the aid of the arms, to a perpendicular. In nearly 
every case, at an early stage, the muscles of the calf of both 
legs begin to develop and become large and hard ; they are apt 
to become enormously developed, as do also the glutei and 
other muscles. While some of the muscles are becoming 
hypertrophied, others are gradually paralyzed and atrophied. 

The distribution of the atrophy and paralysis, and of the 
hypertrophy, is very uneven and irregular. 

The gait is characteristic ; it is very awkward, a rolling or 
wabbling gait ; something of a duck walk. The feet are kept 
wide apart and the shoulders thrown far back. Any extra 
strain on the muscles, manifestly increases the difficulty of 
walking. At times, the patient has to exercise considerable 
ingenuity in order to walk at all, and gets into very ludicrous 
positions in attempting to walk. In the late stages, the child 
becomes absolutely helpless. There is apt to be contracture of 
some of the muscles, notably of the posterior leg muscles, caus- 
ing a true talipes equinus. 



PARALYSIS OF THE PORT 10 DURA. 703 

The mind is affected to the point of idiocy in many cases, 
but probably not by this disease ; it is rather an accompani- 
ment produced by the same inherent cause, whatever that may 
be. In many cases, the mind is as bright and clear as in other 
children of like age. There is at no time any febrile disturbance. 

Prognosis. — The prognosis is decidedly bad. 

Treatment. — Various forms of baths, massage, and the Fara- 
dic current have been recommended, and in a few cases, it is 
claimed the disease has been arrested. I have never treated a case. 

Paralysis of the Portio Dura, or Facial Paralysis, should 
be specially noted. It may be serious or of little import, de- 
pending on its cause. This paralysis may be occasioned by a 
lesion at any point along the course of the nerve, from its pe- 
ripheral termination to its origin in the floor of the fourth 
ventricle. 

Causes. — The peripheral portions may be injured by exposure 
to severe cold — a very common cause — by being involved in 
inflammation of surrounding tissues, by blows on the face, or 
at birth by the forceps during labor. In the portion passing 
through the fallopian canal, it may be involved by caries of the 
petrous bone, usually from otitis, or by fracture of the base of 
the skull. Within the brain we may have as causes, tumor, 
hemorrhage, effusion, thickening of the membranes, abscess or 
exudation. 

Diagnosis. — In diagnosticating this condition, you will exam- 
ine carefully in every case as to the presence of any discharge 
from the ear, or any indications of trouble in the ear; the con- 
dition of the muscles of the tongue and palate, the presence of 
any collateral brain symptoms, or of any sensory symptoms. 
Follow the anatomical distributions of this and other cranial 
nerves, that might be implicated, from their source along their 
entire course. 

If the paralysis is noticed at birth and is confined to one 
side of the face, a comparatively speedy recovery is almost 
certain. 

If the paralysis is peripheral, the affected side of the face 
will be smooth, the eye will not close or will only partially 
close, and when the child laughs or cries the sound side of the 
face will be drawn and wrinkled naturally, while the paralyzed 
side will remain immobile ; the mouth will be drawn to the 
sound side ; the eye on the sound side opens and closes natur- 
ally, that is, you will notice that in all things in which the 
muscles of the face are called into action, those on the sound 
side respond, while those on the paralyzed side remain passive. 

If the paralysis is the result of exposure to severe cold, 



704 THE DISEASES OF CHILDREN. 

massage and electricity will almost invariably result in a cure 
in a few days or weeks. If the result of a blow on the face, 
the prognosis will depend on the extent of the injury. If 
there be a cut severing the nerve, not followed by sloughing or 
ulceration, you may quite safely predict a speedy recovery. If, 
however, there is extensive sloughing, ulceration, or an exten- 
sive abscess should form, there may be destruction of a sufficient 
extent of the nerve to render reuniting impossible. 

If the paratysis is the result of inflammation of the surround- 
ing tissues, the prognosis depends entirely on the extent of the 
destruction of the tissues. In these cases, after the inflamma- 
tory conditions are cured, the treatment of the paralysis is the 
same as for the uncomplicated cases, the difference being that 
in the most severe cases you cannot predict results. It is 
sometimes advisable to cut down upon the nerve, and either 
loosen it from adhesions that have formed, or take up the two 
ends of the nerve and stitch them together. 

If the lesion is in the fallopian tube, the muscles of the soft 
palate will be affected, the uvula hanging to one side; the arch 
of the palate will be flattened on the same side as the facial 
paralysis. There is a tendency for the mouth to be dry, often 
there is some difficulty in swallowing, and there may be a 
tendency for liquid to regurgitate through the nose. There is 
frequently a tendency for food to collect between the teeth 
and the cheek, or difficulties experienced in moving food from 
that side of the mouth with the tongue. These symptoms are 
added to the paralysis of the side of the face. There will, 
nearly always, be in conjunction an offensive discharge from 
the ear. With this combination present there is certainly 
trouble within the tubes, and the prognosis depends entirely on 
that of the producing disease. 

The treatment consists in preserving the nutrition and life in 
the paralyzed muscles, and such as is indicated for the cure of 
the producing disease. 

If the lesion is within the cranial cavity, there will be disturb- 
ances of sensibility, squinting, deafness, or a hemiplegia ; there 
will be evidences of brain lesion affecting other nerves as well 
as the facial. 

A paralysis of the sensory branch of the fifth nerve is some- 
times found in conjunction with that of the facial. If the 
affection is posterior to the Gasserian ganglion, there will be 
anesthesia of the side of the face, but not of the conjunctiva. 
If anterior to the ganglion, there will be anesthesia of the side 
of the face, also of the conjunctiva. There will be danger of 
ulceration of the cornea, and anesthesia of the anterior half of 
the tongue. 



GENERAL TREATMENT OF PARALTSIS. 705 

Prognosis. — The prognosis is necessarily that of the intra- 
cranial producing lesion. 

Treatment. — The treatment consists in the preservation of 
the local muscular nutrition and that adapted to the intracranial 
lesion. 

The General Treatment of Paralysis. — The nutrition 
and integrity of the paralyzed muscles must be maintained as 
far as possible, in order that, when the motor impulse can be 
transmitted from the motor center in the brain to the muscles, 
they can respond. Therefore, while the lesion, whatever it 
may be, producing the paralysis, is being treated, the muscles 
themselves must receive their share of attention. Very fre- 
quently one or the other is neglected. The one most fre- 
quently neglected is the producing lesion. 

If there be no tendency to atrophy other than comes from 
non-use, thorough massage and kneading daily, for from half to 
an hour should be applied. It is wise to have massage to the 
entire body, to assist in maintaining the general equilibrium of 
muscle tone and of the circulation. Some form of oily sub- 
stance should be used with the massage, such as cocoa butter, 
vaselin, olive oil, and others. 

Passive exercise of the muscles should be given every day ; 
an attendant should, a number of times each day, gently move 
the paralyzed member or members in every direction, flexing 
and extending, adducting and abducting, and from time to 
time have the patient make efforts to resist these movements. 
Stretch and relax every affected muscle in the affected part. 
If there is a tendency to contracture, either from position, or 
from central irritation, the shortening muscles must be placed 
on a stretch, for from fifteen to thirty minutes, six or eight 
times a day. If this is not sufficient to prevent contraction, 
some form of mechanical appliance should be devised for each 
individual case. Where possible, the appliance should be fitted 
with rubber bands, or what are called rubber muscles. While 
it is better not to have the tension too rigid, it must be strong 
enough to keep the contracting muscles on a tension ; the ap- 
paratus should not, except in rare cases, be worn constantly. 
It may be worn for stated periods of one, two, or three hours, 
and from one to three times a day, depending on the judgment 
of the attending physician, and not at all on that of the patient 
or friends. It is advisable to encourage the patient to make 
frequent efforts to move the paralyzed muscles by their own 
volition. Be careful, however, in doing this, not to allow the 
patient to become discouraged because it is so long before they 
can succeed. 

D. C— 45 



706 THE DISEASES OF CHILDREN. 

Electricity is an almost universal remedy for paralysis. It 
has- done much harm and some good in the hands of the laity, 
quacks, and those physicians who will not take the trouble to 
familiarize themselves with its sphere of action, its indications 
and contra-indications. It should be studied with the same 
care as any other remedy. 

It has accomplished wonders. It will do, just as any other 
remedy will, certain things that nothing else will. Excepting 
where I have suggested its use for the special lesion, it should 
not be applied in any case of organic, sudden paralysis until 
one or two weeks after the onset. I almost invariably use both 
the galvanic and the Faradic currents. I rarely, almost never, 
use the static in the treatment of paralysis. 

Any of the batteries or machines found in the surgical instru- 
ment houses will answer the purpose. It is wise to use a mille- 
ampere meter always with the galvanic current, but in this 
kind of work it is not an absolute necessity. A twelve-cell 
portable galvanic battery and a Faradic machine, or a combined 
galvanic and Faradic battery, will answer the purpose. Of 
course a stationary office battery, or a more powerful portable 
instrument may, in rare instances, be needed. 

I first test the paralyzed muscles with the galvanic current, 
commencing with a very mild current, interrupted within the 
metal circuit, and gradually increase the strength until the 
interruption produces a spasmodic motion in the paralyzed 
muscle, provided such result can be obtained without too severe 
pain, or the production of cutaneous electrolysis. Now, note 
the direction in which the current has been passing, the num- 
ber of milleamperes or the number of cells necessary to produce 
the spasmodic motion, then reverse the current and test as be- 
fore, noting the strength of current required to produce the 
same effect. In the treatment of the paralyzed muscles, use 
the current in the direction from which you get action from 
the current of the least strength. Use a current of just suffi- 
cient strength to produce mild contraction. Give it from two 
to three times a week. Make each application, if to individual 
small muscles, from two to three minutes. If to individual 
large muscles, from five to seven minutes; if to an entire limb, 
from fifteen to twenty minutes. The pole nearest the center 
may be placed over the spine, or over a nerve trunk at a point 
where it lies near the surface, and between the paralyzed part 
and the spine or head. The opposite pole is to be applied 
over the motor nerve points of the paralyzed muscle. The 
current should be interrupted within the metal circuit from one 
to twenty times per minute. 

The Faradic current is to be applied to the paralyzed muscle 



GENERAL TREATMENT OF PARALTSIS. 707 

for the purpose of retaining muscular nutrition, retaining 
muscle habit of contracture, and exercising the muscle. The 
direction is, for the most part, immaterial. It should be ap- 
plied directly to the paralyzed muscle. It may be by means 
of a foot bath, with one of the poles dropped into the water 
near the foot, or a large wet sponge electrode may be placed 
under the feet, the other electrode being applied over the 
various parts of the paralyzed muscle, particular attention being 
paid to those points causing marked contractions in the mus- 
cles. Both electrodes may be applied by the physician in such 
manner as to produce marked contractions at all parts of every 
affected muscle. This can be accomplished by applying the 
electrodes transversely through the various muscles, or longi- 
tudinally. The current should be of sufficient strength to pro- 
duce marked, but not excessively painful, contractions in the 
paralyzed muscles. The application should be daily and from 
fifteen to thirty minutes, except where individual muscles only 
are affected, then a shorter time, depending on the size of the 
muscle. Where there is marked muscular contracture that 
does not yield to mechanical means alone, the galvanic current, 
applied regularly from ten to twenty minutes, over the con- 
tracted muscles without any interruptions in the circuit, may 
be of decided service. The Faradic current, applied to the 
opposing muscles strong enough to produce contractions in 
them of sufficient force to place the contracted muscles on a 
stretch, will frequently assist in overcoming contracture. 

In the treatment of paralysis, electricity is not beneficial un- 
less followed up thoroughly and with judgment. The giving 
of an occasional application is useless. In those cases where 
there is atrophy of the paralyzed muscles, due to central tro- 
phism, and where it is impossible to get contractions from a 
safe strength of current, apply as strong a current as can be 
borne without injuring the skin, or frightening the httle patient 
to a detrimental degree. 

In general, where you cannot get a guide as to the proper 
direction in which to run the current, apply the negative at the 
more distant and the positive at the nearer point toward the 
spine or head. If anesthesia is present, the electrical brush 
will frequently be of great service. The application should be 
daily or on alternate days, and not exceed from three to five 
minutes, with a current of sufficient strength to make the skin 
pink. 

Where atrophy of the paralyzed muscle is prominent, the 
massage, the oiling, and the electricity should all be used, and 
in addition, heat. My preference is moist heat. There is no 
end to the variet^^ of baths prescribed for cases of paralysis. 



t08 THE DISEASES OF CHILDREN. 

Any of them are useful if given properly. In cerebral paraly- 
ses, heat treatment or hot baths are not usually indicated, and 
many times are positively dangerous. Thus, in hemorrhage, 
thrombus, tumor, or softening of the brain, or if there is a tend- 
ency to congestion, heat treatment may, in any hands, prove 
instantly fatal, or do irreparable damage. 

Baths may be local or general, that is, applied to the para- 
lyzed parts, as recommended under polyomyelitis, or to the 
entire body. The object of the heat treatment is to elevate 
the body temperature. If the paralyzed member alone is given 
the bath, its temperature must be raised by the bath, if any 
good results are to be obtained. If the bath is to the entire 
body, the body temperature must be raised. It is my custom 
to take the temperature of the patient under the tongue on 
entering the bath, to regulate the temperature of the water, or 
of the steam or hot air chamber, and the length of the time of 
the bath in such manner that the temperature under the tongue 
is raised from one to two degrees. On coming out of the bath, 
the patient may be allowed to lie in a pack for a time, or be 
immediately rubbed dry with a coarse towel, vigorously used. 
I am confining these directions to paralytics. Thorough mas- 
sage may be used immediately following the bath, or at some 
other time in the day, depending on the special condition of 
the patient. In the atrophic cases, where the circulation is 
markedly decreased in the paralyzed muscles, what is known 
as the vacuum treatment, will often be of very great service. 
An arm or a leg, or both legs, or the entire body from the neck 
down may be placed in the receiver. This treatment should 
be followed up daily. Care must be taken to exhaust the air 
sufficiently to force the circulation into the capillaries, but not 
to produce stasis in them. 

In all cases of paralysis the functions of the bladder and 
bowels must be continuously and carefully looked after. 
Where constipation is the direct result of the producing lesion, 
and not the fault of the digestive organs themselves, mechani- 
cal means must be used to move the bowels. In these cases I 
think I have had more satisfactory results from the internal 
administration of ox gall, either alone or in some combination, 
than from any other laxative. A common prescription with 
me is: 

H Fel. Bovinum Ex grs. 60 

Hydrastia Mur grs. 3 

Aloes Aqueous. Ex grs. 3 

Calabar Bean. Tr , gtts. 24 

Div. Capsules 12 

Mx. 



GENERAL TREATMENT OF PARALTSIS. 709 

One at night is usually sufficient to cause a free and easy 
movement of the bowels each day, without any appearances of 
cathartic action. Occasionally it will be found necessary for a 
short time to give two or three a day. Aluminum 30c, natrum 
nur. 30c, opium 3X or 30c, mix vom. 3X, and other remedies 
will sometimes accomplish the result. I never use the mechan- 
ical means when I can obtain results from the best selection of 
a remedy I am able to make. In some cases I find it neces- 
sary to use enemas in the rectum or up into the colon. 

Remedies must be selected to cover the particular lesion and a 
paralysis. It is obviously impossible to indicate a list of reme- 
dies for paralysis in general. A list that may be indicated in 
the various paralytics, would comprise nearly the entire materia 
medica. My own experience has been that when I had ten or 
fifteen remedies that I considered adapted to paralysis, I did 
not affiliate my remedies as closely, nor obtain as good results, 
as I do now. My method of late years has been to first look 
for my indications, without considering the factor of paralysis 
at all. I look for a remedy that will cover the symptoms and 
the pathology proximately. I use the word proximately here 
for the reason that there are many lesions that must be con- 
sidered as traumatic or accidental, and it is obviously impossi- 
ble that any remedy can be homeopathic to these. 



CHAPTER VI. 

HEREDITARY ATAXY. 

In this there is degeneration in several of the columns of the 
spinal cord, the posterior columns being most profoundly af- 
fected. The lateral columns become affected almost invariably 
in the course of the disease. 

The heredity is rarely direct ; that is, it is not common for 
the parents to have had ataxy, although this does occur some- 
times. Dissipation, syphilis or insanity in the parents, or any 
of the conditions that reduce materially the nerve force of the 
parent, are likely to beget a neuropathic child, a child particu- 
larly susceptible to nerve trouble. 

In this particular form of ataxy, it is supposed that the 
posterior and possibly the lateral columns, are defective at 
birth. 

It seems to be more common in America than in any other 
country, but even here there are less than seventy cases re- 
ported. In this country it seems to be more common in girls 
than in boys. The first evidences usually appear at about pu- 
berty, sometimes, however, as early as eight years of age or as 
late as sixteen years of age. In some instances, several chil- 
dren in one family are afiflicted. The duration is from five to 
twenty years. 

Symptoms. — The early symptoms are a weakness of the legs, 
soon followed by an uncertainty in their movements. The patient 
loses the power of making various motions as he desires ; the 
foot, unless aided by the eye, cannot be placed on a certain in- 
tended spot. The patient is uncertain as to the position of his 
feet and legs ; he is unable to tell, at times, whether a leg is in 
the bed or hanging out, whether the legs are crossed or not. 
Vertigo is likely to be present. There is usually some pain, 
but not marked. Within a year from the onset the knee jerk 
is abolished. The cutaneous reflexes are likely to be more or 
less interfered with and are apt to be irregular. 

The disease is essentially a progressive one. There may be 

long periods in which there is no noticeable change. In five 

or six years, symptoms, similar to those in the legs, appear in 

the arms and hands; the patient loses the power of determin- 

(710) 



HE RED I TART ATAX T. 711 

ing, by sensation, the difference in the shape of objects placed 
in the hands : also the power of determining, by sensation, dif- 
ferences in the weight of objects. Later, the patient loses the 
control of the tongue, and is unable, while perfectly familiar 
with words, to use the tongue in a way to articulate with any 
certainty. The head may now have an oscillating motion, and 
the extremities become choreic. In most cases, some form of 
talipes is developed. Nystagmus is common, other eye trou- 
bles are rare. There is no optic neuritis or atrophy. The 
bladder and rectal conditions are not interfered with. There 
are many symptoms occurring in occasional cases, but those 
mentioned are essential to the disease, and are sufficient to 
determine the diagnosis. 

Prognosis. — The chances of recovery are not good ; very few, 
if any, cures are reported. 

Treatment. — The patient should be kept as quiet as possible, 
free from all excitement, and have very little physical exercise. 
The environments should all be of the best. The hygienic and 
sanitary conditions as perfect as possible. 

Massage should not be used. Passive exercise is not to be 
given. The heat treatment, with just sufficient surface rubbing 
to get skin reaction ; great care, however, must be used not to 
burn or scald the skin. The baths, if used, should not be 
oftener than twice a week. Electricity should not be admin- 
istered. 

Spinal extension, using Sayer's apparatus, beginning with 
fifteen seconds, gradually lengthening the time to two minutes 
every alternate day, should be used in every case. Nerve vi- 
bration promises to give results in these cases. It should be 
applied daily for a number of weeks, with intermission of an 
equal length of time. The hammer should be applied over the 
entire soles of the feet, over each tendon at the base of the 
toes on the upper side of the foot, just behind each malleolus, 
over the internal and external saphenous nerves, over the an- 
terior tibial at the instep, on the popliteal nerve in the pop- 
liteal space, over the external popliteal as it passes over the 
external condyle of the femur, along the course of the sciatic 
nerve, over the femoral nerve in the groin, and over correspond- 
ing points in the hands and arms. I use about two minutes on 
the sole of each foot, and one minute at each of the other 
points, making every treatment as near uniform as to time of 
day and order of procedure as possible. 

While I have had no experience with this treatment in the 
hereditary ataxy, I have had sufficient experience with it in the 
ataxy occurring in adults to warrant the statement that it is a 
curative agent of great value in ataxy. 



712 THE DISEASES OF CHILDREN. 

Acquired Locomotor Ataxy, it is claimed, occasionally 
occurs in children. While a case has never been presented to 
me, the reports are from men whose diagnostic attainments 
forbid doubt. 

The symptoms would be the same, except that the progres- 
sion is less marked ; there is likely to be diplopia early in the 
case and optic atrophy later. 

The prognosis and treatment would be the same. 



CHAPTER VII. 

IDIOCY. 

Authors are agreed in recognizing idiocy, imbecility and 
feeble-mindedness, as grades of the same condition. There is 
no difference except in the degree of mental development, the 
idiot possessing the lowest possible mentality, the imbecile the 
greater mentality, and the feeble-minded approaching to that of 
other children, of like age and advantages, in its reasoning 
powers. 

Causes. — The cause is primarily a lack of cerebral develop- 
ment, either of all parts of the brain, or of individual portions. 
This lack of development may be due to prenatal or to post- 
natal influences. 

Insanity, hysteria, alcohoHsm, great excess in the use of 
tobacco, opium, chloral, or other drugs, organic nerve disorders 
of the more profound type, syphilis, tuberculosis, great dissipa- 
tion in social or business life, constant criminal life, and pro- 
longed and excessive sexual dissipation in the parent or parents, 
without doubt tend to arrest regular cerebral development. 
Long-lasting labor, by keeping the head compressed unduly, 
causes many babies to be born with suspended animation. 
Statistics show that a large percentage of those mentally defec- 
tive, had suspended animation at the time of birth. The 
general health of the mother, any violent emotion or profound 
and protracted grief during gestation, may affect the brain de- 
velopment of the child. 

Cerebral and meningeal hemorrhages, thrombus or embolism, 
occurring either at birth or subsequently, may cause an arrest 
of development. Cerebritis, and cerebral meningitis in infancy, 
or frequently repeated and severe convulsions, are fruitful 
sources of irregular and defective development. 

Any disease of the brain that produces pressure or serious 
disorders of the circulation of the brain, may cause defective 
development. 

Irritation of the genital organs, either from anatomical malfor- 
mations, or from masturbation in either sex, play a not insig- 
nificant part in producing imbeciles and the feeble-minded. To 
cigarette smoking a number of cases are clearly due. 

Profound emotions, such as fright, sometimes seem to arrest 

(713) 



714 THE DISEASES OF CHILDREN. 

development. Traumatism of the head comes under the dis- 
eases of the brain that may effect its development. The inter- 
marriage of close relatives does not have any influence. 

Many cases are found where it is impossible to form any idea 
as to the cause. 

I shall not here make any classification, other than to call 
attention to differences between the congenital and the 
acquired. 

In the congenital cases, there are frequently deformities of 
the body as well as of the brain, while in the acquired this is 
very uncommon. In the congenital cases, the mental devel- 
opment, if there be any, is slow and somewhat regular from 
birth. In the acquired cases, the history will show that the 
child, up to a certain time, was as bright, mentally, as other 
children of the same age, having like opportunities and envir- 
onments; then some accident, an attack of sickness, or of long- 
continued, frequently recurring, severe convulsive attacks, and 
with no mental development from this date, or a very slow de- 
velopment from this time. 

In some cases the child loses, during an acute infectious or 
febrile disease, almost all mentality, temporarily only. At 
other times the mentality is permanently lost, so that the child 
has no more mind than a babe. The mental development may 
progress slowly but steadily from the time of its arrest. 

In many instances there is found an exceedingly low grade 
of mentality, a pronounced idiocy, and yet great brightness is 
shown in some one direction. It is not very rare to find the 
feeble-minded person, that is far above the average in some one 
thing. I have a little patient of nine years who has locality so 
thoroughly developed that, even though a stranger in this large 
city, he will remember any place or building that he has ever 
once casually seen. I had a case, a little girl of ten, with a 
general mind certainly not over two years, that seemed to never 
forget a date. One of our greatest cat painters was an imbe- 
cile. These peculiar, single precocious traits may lead in any 
direction. Imbeciles and idiots are also often deaf and dumb. 

It is not always an easy matter to determine whether a child 
is a mute, or whether there is not sufficient intellection to give 
evidences of hearing and to converse. I do not intend to say 
that there are many cases of this kind, but occasionally it is 
found, by prolonged and close scrutiny, that the hearing is 
fairly good, when for a number of years the family and friends, 
and even ^expert aurists, as well as neurologists, have been cer- 
tain of total deafness. A child deprived of sight and hearing 
from birth, or at an early age, may, from this alone, be feeble- 
minded. 



iDiocr. 715 

The feeble-minded of all grades differ as much in tempera- 
ment as sound people ; among them are found the amiable and 
the irritable, the cheerful and the morose, the tractable and the 
stubborn, the quiet and the noisy, the gentle and the vicious. 

There maybe associated with the feeble mind hallucinations, 
delusions and illusions. There may be moral defects of nearly 
all kinds and grades. 

Treatment. — Treatment of all grades of the feeble-minded 
imposes on the physician the gravest responsibility. The ten- 
dency to pure routinism, and to be perfectly satisfied by furbish- 
ing an asylum, is directly chargeable with preventing many 
persons from becoming useful members of society. The phy- 
sician who only casually looks at a case of this kind and does 
not learn everything that is to be learned about the patient, 
the hereditary influences and the environments, fails in his 
duty. If he has not the knowledge, ability, time, or interest 
essential to the careful and thorough examination, he should 
command the parents or guardians to consult some one who 
can and will care for the case intelligently. The excuse that 
there is no place for them where intelligent treatment can be 
had, is no longer tenable. There are institutions, both private 
and public, in various parts of the country, under the care of 
reliable, educated, intelligent and enthusiastic physicians. 

The first element in deciding on a line of treatment is, to de- 
termine whether congenital or acquired, and the cause. Is the 
cause one that is still active, is still a cause of interference of 
development, a present source of irritation, or has it done the 
damage and ceased to be active? If there is any present source 
of irritation, or of interference with the circulation of the brain, 
or of its nutrition, or anything that might possibly act in this 
way, treatment should be directed to its cure. If convulsions, 
try to cure them ; if a depressed section of bone, remove or 
elevate it ; if an adherent prepuce, circumcise. Whatever pos- 
sible present source of irritation, or interference with circula- 
tion or development of the brain can be found, I again say, 
undertake to cure it. 

The next step in the treatment looks to a perfect general nu- 
trition. Proper food and good air, hygienic and sanitary sur- 
roundings, and judicious physical exercise, must all have care- 
ful attention and be intelligently prescribed. The matter of 
physical development is probably as important as any one 
element of treatment, and usually receives almost no attention. 

In the line of remedies, I have found unmistakable good re- 
sults where some cachexia was present, or where they were 
prescribed for the cure or removal of a present acting cause. 
AVhere the only indication I can find is the feeble, undeveloped 



716 THE DISEASES OF CHILDREN. 

mind, there is but one remedy that I have found to be of any 
advantage : ziyic phosphid. I give it usually in the 2x or 3X 
trituration, sometimes the ix, from three to four doses per day, 
and continue it for months. 

The next element in treatment is education. The good that 
can be accomplished in this direction is only just beginning to 
be appreciated. I am astounded by results I have seen in 
some of our institutions during the last five years. I am 
sorry to be obliged to admit that results, that I have said were 
absolutely impossible to proximate, have been accomplished. 
In this connection the question as to home or institutional 
training confronts the physician at once. The mother knows 
that she can train and manage her child better than any one 
else. There is in the families of the middle classes, a senti- 
mental desire to care for the child at home. Among the labor- 
ing classes and the poor, we find many who are strongly 
opposed to any hospital or asylum ; on the other hand, many 
of these classes are perfectly willing to allow the child to 
be taken care of at a proper institution. The very rich are 
rather inclined, so far as my own experience goes, to keep 
these children in seclusion and provide a private attendant or 
governess. 

By far the best plan is the training in an institution, for this 
class of children. The plea that association with the feeble- 
minded only is injurious, does not hold in actual experience. 
In an association with others of nearly the same mentality, 
everything about the child is brought within the range of its 
possible comprehension. Comprehension is the all essential in 
the training. There is not the discouragement of nothing but 
the, to them, incomprehensible. Much is comprehended by 
association with other like children, while very little is learned 
from association with children of ordinary mental endowments. 
The frictional irritation of brighter children about, is also an ele- 
ment in retarding good moral development. The mother 
rarely uses anything approaching to even, smooth, firm discipline 
with this kind of a child, no matter how good the discipline over 
her other children may be. 

A private governess is usually not trained for the manage- 
ment of this particular class of pupils, and even if one is se- 
cured, who has the necessary training, the life soon becomes so 
monotonous that the enthusiasm is lost, and she cannot do the 
best that can be done for her charge. 

As to the best method of training, no specific directions can 
be given. Each patient must be studied individually, and 
the training adapted to its peculiar needs. 

There are a large number of children who belong to the 



iDiocr. iVi 

feeble-minded class, who are only enough below the average 
child to learn very slowly and laboriously. They can be trained 
at home, under a governess, or in the school. Care must, 
however, be taken to secure teachers who will exercise patience 
and are willing to lead slowly. Care should also be observed 
that the child is protected, as far as possible, from the sharp 
shafts of ridicule so apt to come from playfellows. 



CHAPTER VIII. 

INSANITY. 

Insanity is not common in children, but is occasionally 
found. The percentage of the insane increases with age. It 
is very rare before five years, less so between five and ten, still 
less from ten to twenty ; after the twentieth year it increases 
quite markedly. 

Causes. — The first cause to be considered is heredity, direct 
and indirect. The proportion having insane parents that are 
afflicted with the same trouble, or direct heredity, is much 
greater than in most diseases of the nervous system. The va- 
rious diseases and habits prone to produce the neuropathic 
child, or indirect heredity, are fruitful sources of insanity. 
Traumatism, emotional shocks, or the various diseases that in- 
terfere with cerebral nutrition, may cause it. Many cases are 
the direct result of reflex irritation. In all cases, even in quite 
small children, the rectum, anus and genitals should be care- 
fully and thoroughly examined. Masturbation is not as common 
a cause as many authors claim, but there are many cases 
directly chargeable to it. Neither sex is free from this habit, 
although boys outnumber the girls by a very large majority. 
If this habit is taught a very young child by a nurse, an 
attendant, or by older children, it must and does work great 
harm, by its profound effect on the only partly formed, sym- 
pathetic nervous system. The entire vasomotor system is 
rendered permanently unstable, and perfect, uniform, well-bal- 
anced nutrition of all parts of the body is impossible. If 
the habit be learned at a later age, say after the tenth year, 
the harm is not nearly so great ; the injury then depends on 
the frequency of the act, and the duration of the habit. In 
this connection I must mention a large number of more or 
less pronounced melancholies where the cause is not mastur- 
bation, but the obtaining by the young man of the erro- 
neous information that the habit is necessarily harmful, no 
matter how little it may have been practiced. Hundreds of 
these cases present themselves to the physician where, on care- 
ful inquiry, it is learned that there has not been a sufficient 
practice of the habit to do any possible harm ; but the constant 
(718) 



INSANITT. 719 

brooding over, and looking for symptoms has rendered life 
unendurable, and produced the symptoms described by va- 
rious ignorant or unprincipled men as the sure result of the 
habit. 

Training and environment have much to do with the causation 
of insanity in children, as well as producing a predisposition 
to it in adult life. Fright is one of the frequent direct causes. 
The habit so many parents, nurses and older people have of 
telling children frightful stories, of threatening them with the 
black man, spooks, etc., etc., cannot be too severely condemned. 
Children with organic disease of the heart are particularly 
susceptible to injury from fright. 

Many cases are the result of the acute diseases of childhood. 
Aside from those cerebral diseases which are prone to produce 
insanity, typhoid fever, diphtheria, scarlet fever and rheumatic 
fever are the ones most frequently followed by it. 

Puberty is a favorite time for the appearance of many 
diseases. Insanity is no exception. The sexuality of both 
male and female is so great a part, anatomically and physiolog- 
ically, of the emotional element, and the emotions in their 
turn are so important a factor in all mentality, that anything 
pertaining in any way to it can but have a profound influence. 
Correct knowledge and a careful guard, mentally and physically, 
as to sexual matters are therefore important in the training of 
boys and girls, when approaching puberty. 

Symptoms. — A peculiar form of insanity is not at all uncom- 
mon in girls about puberty. It commences with a slight actual 
indigestion, and very soon develops into a pronounced phys- 
ical indigestion. The patients being fully convinced that they 
can take no food of any kind into the stomach without great 
injury, frequently imagine, if of a religious turn, that the 
taking of food is a sin. The physician must, by a careful 
examination, satisfy himself thoroughly that there are no 
physical conditions that can produce the apparent digestive 
disturbance, and then either send the patient to an institution, 
or proceed to forcibly feed him through a stomach tube, 
if necessary. The physician must see personally that a 
sufficient quantity of good nutrition is introduced into the 
stomach regularly, and that the patient does not of her own 
volition, by running the fingers down the throat or otherwise, 
eject the food. If there be no source of irritation present, no 
other treatment will be needed. 

Insanity in children takes various forms. There may be oc- 
casional outbreaks of acute mania with perfectly lucid and 
healthy intervals. It is much more common, however, to 
meet cases in which there is a perverted morality. It may be 



720 THE DISEASES GF CHILDREN. 

a pronounced egoism, selfishness or ill-temper; there may be 
an intense desire to see and do cruel things, either to insects, 
animals or to persons. There may be a constant tendency to 
theft, or to some other special moral wrong. 

Diagnosis. — The diagnosis must be made by a careful con- 
sideration as to whether the child's life and acts are at all in 
harmony with its environments. That which is insane in a 
child under certain environments, under others, may be per- 
fectly sane. 

Treatment. — If there is not a pronounced heredity or a suf- 
ficient emotional shock, there is some physical condition acting 
as a producing cause. It is the duty of the physician to find 
this cause. It may take time and a large amount of patience, 
but it is there and must be discovered. 

The treatment of these cases must first be directed to the 
cure of any possible source or reflex irritation, or the removal of 
any direct irritation. Cerebral surgery, while not often called 
for, may in any case be a source of possible relief, and indica- 
tions for it must be sought in every case. 

The urine should be, as in all neurotic cases, analyzed quan- 
titatively. It may be found that a simple chronic uremia is 
the source of all the trouble, or there may be an exceedingly 
small percentage of phosphoric acid excreted. The corrections 
of these will alone cure some cases. 

The moral treatment, as it is termed, is of the greatest im- 
portance. There should always be firm, even, regular, kindly 
discipline. The child is unable to control itself; it can only 
learn self-control by being controlled, and under no circumstances 
should the child be under the management of any person 
who has not perfect self-control. Harsh measures are un- 
necessary and harmful. Asylum treatment, unfortunately, 
cannot always be obtained for children. Where the parents 
are able, the child should always be placed in charge of a well- 
trained and competent nurse. If the parents cannot afford 
this, the physician must instruct the family again and again as 
to the smallest details of management, and keep a close, per- 
sonal watch over the case constantly. It is often possible to 
find a good, level-headed, motherly woman, without children 
of her own at home, exceedingly well adapted to the care and 
management of an insane child, who will take charge, at her 
own home, for a very moderate compensation. 

The remedies I have found useful in the insanities of children 
are ; aconite^ ammonium carb., apis mel., arnica, arsenicum, 
baryta inur., belladojina, cactus, calcarea carb., calcarea phos., 
cantJiaris, capsicum, causticiim, chamomilla, cimicifuga, etna, 
cuprum, f err um phos., gelsemium, helleborus, hepar, sulph., hyos- 



HTSTERIA. 721 

cyamous, hypericum, ignatia^ iodium, kali curb., kaliphos., mer- 
curius, moschus, nux vom., mix moschus, opium (very carefully), 
psorinum, secale, silicia, stramonium^ veratrum. album, vera* 
trum viride and zinc phos. 

Hysteria. 

Every physician is called upon to treat cases of hysteria in 
children, in both boys and girls, previous to puberty. While 
there are more cases in girls, there is a much greater propor- 
tion of boys affected by this disease than is ordinarily realized. 
Many cases are not diagnosticated, simply because the patient 
is a boy. 

Causes. — Heredity plays an important part in the causation 
of hysteria. The transmission may be direct from hysteria in 
the parent, which in this disease is quite frequent, or indirect, 
one or both parents having been aiiflicted with some of the dis- 
eases, or addicted to habits that are likely to produce neuropathic 
offspring. 

Training and education are prolific causes. If it were possi- 
ble to have every child judiciously trained and educated, hys- 
teria would be a rare disease. Those predisposed would almost 
never have it develop, and others would be cured before de- 
velopment. Discipline should begin in very early infancy ; a 
new-born babe may be taught to take its food at regular 
hours, to go to sleep and remain so at and for regular times, 
without holding, rocking or carrying. A young babe can 
learn that, if it cries on account of pain, it is always promptly 
attended to ; and that when it cries from disappointment, or 
simply because it wants something different, the crying does 
not result in accomplishing the object. The young child can 
very soon be taught to realize that, no matter how kind and 
indulgent a parent may be, repeated asking or teasing never 
does any good ; that, when the parent believes a thing is not 
good, it never comes ; that if a parent thinks a certain thing is 
for its benefit, it is invariably done. When '' Yes, my dear," 
and " No, my dear," are each spoken with the same tenderness 
and in the same tone, the mother is teaching and the child is 
learning. A parent should never lose control of his or her 
temper in dealing with a child. Under no circumstances 
should a parent deceive or lie to a child. The habit of tell- 
ing untruths to a child, of deceiving it in various ways, under 
various pretexts, and of buying the child to do or refrain 
from doing certain things, sows the seeds of hysteria in many 
cases. As the child attains the age of understanding, it should 
be given reasons for doing or refraining from doing. Where 
D.C.— 46 



722 THE DISEASES OF CHILDREN. 

reason within the comprehension cannot be given, simply 
say these things will be explained when old enough to under- 
stand. 

The child should be taught early not to fear. This includes 
an absolute prohibition of the pernicious habit of telling ghost 
or other frightening stories, and of endeavoring to obtain 
obedience through the agency of fright. If the physician has 
to do anything that is likely to hurt the child, it is much bet- 
ter to tell the child it will hurt, and endeavor to arouse its 
pride to appear brave, than to lose its confidence by lying to it. 
If a child loses its confidence in its parents and physician, how 
can we expect the child to be true ? 

Education, in matters of book learning, and the develop- 
ment of the mental powers, is a matter to be studied in each 
individual case. There is no more fruitful source of hysteria 
in the young, or of hysteria and chronic invalidism in the adult, 
than a too rapid mental development during the formative 
period of life. If a child happens to be ever so little brighter 
than the average — and whose child, unless it be an idiot, is 
not? — all the friends of the family must know it. Parents tell 
me almost daily that they do not teach their little children 
anything, that they try to hold them back ; but what is the 
fact ? Every little thing the child learns from association is 
commented on to every one in the child's presence, and every 
little couplet must be repeated before every one that calls. In 
short, the child must show its every accomplishment, and be 
unduly praised for it. In this way, for the sake of praise and 
adulation, the child is stimulated to make mental effort when it 
should be only developing the physical. I do not object to 
encouragement by praise, but the praise should be for such 
things as will help a physical development, rather than the 
mental, except in those cases where the mental is unnaturally 
slow. The grade of mentality, in independent thinking and 
reasoning, of the human race would, I believe, be materially 
elevated if school life began at nine rather than six or seven 
years of age. Education should have for its prime object com- 
prehension, not simply abstract memory. Make the brain a 
reasoning organ, not simply a storehouse. 

Every child should have a maximum of outdoor life, exercise 
that tends to develop every muscle in the body, and plenty of 
it, but avoid heavy straining at any time. 

Look to the child's sleeping-room, or to the nursery, and see 
that it is so located as to get a maximum of sunlight and air. 
Do not let an architect put these rooms in any part of the 
house, simply so that it does not interfere with the general 
symmetry. Do not take the sunniest and airiest room in the 



HTSTERIA. 723 

house for a spare room, and relegate the children to any little 
dark room. 

Imitation is the cause of many hysterias. From this cause 
there occasionally occurs an epidemic of this disease. An epi- 
demic may run through an institution or a school. All of the 
cases will be of the same kind. Within the same family, one 
child may imitate an actual disease of some other member, or 
one member may have some form of hysteria, and a child 
afflicted, in the same form, by imitation. 

Rapid or severe changes in temperature seems to act as a 
cause at times. 

Memory seems to play an important role. A child sees or 
hears something that makes a profound impression, or has 
something happen to it, possibly an accident, the thought of 
which remaining constantly in the mind, may be the direct 
cause of hysteria months or years after. Many cases of sup- 
posed rabies are hysterical and belong to this class. There is 
in every person of any mental endowment, in addition to the 
ordinary memory, or that which enables us to recall facts or 
things, an unconscious memory ; that is, many things are 
stored away, somewhere in the deeper recesses of the brain, of 
which we are entirely unconscious ; these things exert a far 
wider, deeper, profounder influence in our lives than we can 
possibly appreciate. This memory will, as has been clearly 
proved in many cases, be the cause of a hysteria. 

Any reflex irritation may be the cause of a hysteria. If 
we exclude those cases from direct heredity, and those due to 
faulty training and education, there will be very few cases in 
which some form of reflex irritation will not be found to be an 
important element in the direct causation. So far as my own 
experience is concerned, the chief reflex causes have been in the 
eye, the digestive tract and the genitals. 

I have, however, found every possible reflex irritation to be 
the cause of hysteria. It is not infrequent to have hysteria 
follow or appear during the convalescence from acute inflam- 
matory or infectious diseases. There seems to be a general 
impression that the hysteric is necessarily of a yielding, weak 
nature ; the contrary I believe to be true. The intellectual 
type, of fine sensibilities, those of tenacious and positive opin- 
ions, and the energetic and impulsive people, are most suscep- 
tible to this disease. Another class who are frequently sub- 
ject to hysteria are those of devout nature. Chronic uremia is 
a frequent cause. 

Symptoms. — An attempt to enumerate the symptoms of hys- 
teria would mean the mention of nearly every symptom of 
every known disease. There may be convulsions, paralysis, 



tM THE DISEASES OF CHILDREN. 

contracture, chorea, tremor, ataxy, anesthesia, hyperesthesia, 
paresthesia of any character, pain of all possible shades and 
types, almost any form of mental aberration, and so on through 
the Hst. 

At times the symptoms in their totality will so closely re- 
semble various diseases as to render differentiation quite diffi- 
cult, occasionally, indeed, impossible for weeks. Blindness, 
deafness and mutism are not infrequent in children. Abnor- 
mal excretions, particularly the urinary, are fairly common ; 
many cases of nocturnal disturbances are hysterical. There 
may be an absolute suppression of urine, or in the cases ap- 
pearing near puberty, there may be so much shrewdness in 
disposing of the urine that the attendant finds great difficulty 
in detecting the passage of any urine, and for a time is con- 
vinced of an entire suppression. 

Even quite young children will show a great degree of 
shrewdness in deceiving those about. In some instances the 
deceptions are intentional, and for the deliberate purpose of 
obtaining an object ; but in the true hysteria, there is an irre- 
sistible impulse combined with a degree of self-deception. 
There is always a distinct effort at attracting attention. This 
is often skillfully cloaked, but is always discoverable. Hyster- 
ical symptoms are primarily for the audience, not for the 
patient. 

It occasionally assumes the form of a theriomimicry — that 
is, a mimicking of certain animals, either the sounds made by 
them or their actions. If a hysterical child bites, it is more 
likely to bite some other person, but occasionally they bite 
themselves quite seriously. 

Night terrors may be classed among the nocturnal hysterias. 

We have hysterical talipes of various forms, also hysterical 
hip-joint disease, and spinal curvature. 

We find hysterical anethesias, where the child can be burned 
or cut without the least flinching. 

Persistent somnambulism is claimed by some very high au- 
thorities to be a form of hysteria. We recognize, also, a purely 
hysterical fever; the rise in temperature and concomitant symp- 
toms may occur only at night, or during the day, lasting for a 
short time only, or the fever may last several days. The in- 
creased rapidity of the pulse and rise in temperature may be 
slight. In some cases the pulse will be uncountable, and the 
temperature may rise to iio° Fahr. without indicating danger. 

Catalepsy, ecstasy and trance must, at present, be considered 
as forms of hysteria. These conditions are not common under 
the age of puberty, but are occasionally met. 

Epileptic or convulsive seizures are frequently hysterical. 



HYSTERIA. 725 

Hystero-epilcpsy is now fully recognized as a distinct entity, 
entirely separate from true epilepsy or from organic convulsive 
seizure. It is not always an easy matter to differentiate the 
hysterical from the true convulsive seizures. In not a few true 
epilepsies or convulsive attacks of reflex origin, hysterical con- 
vulsions occur as frequently as the true convulsions. 

Diagnosis. — The diagnosis is of the greatest importance, as 
the prognosis will, in many instances, depend on learning early 
the nature of the disease. Very many chronic invalids, who have 
the sick habit sofully formed that a cure is absolutely impossible, 
might have been easily and quickly cured had the nature of the 
disease been discovered soon after its first manifestation. An 
opinion by a physician of some serious organic disorder, espe- 
cially if confirmed by others, may so thoroughly imbue the inner 
consciousness that no influence can eradicate it. 

The physician will require all keenness of perception, all 
of his shrewdness as well as judgment, to be at all times cer- 
tain of his ground. He must realize that children, especially 
of the class subject to h5"steria, have keen ears and sharp eyes, 
are close observers, have quick perceptions, and bright, shrewd 
intellects. He should, therefore, be very careful as to what he 
says or does in their presence or he may be thwarted in the 
study of the case. 

The diagnosis must be made by exclusion. It is my own 
rule to first look for disease other than hysteria. In fact, it is 
a universal rule with me, whenever I get an early impression as 
to the diagnosis in any case, to undertake to prove that impres- 
sion wrong. There is no greater enemy to success from a 
purely professional point than instantaneous or intuitive diag- 
nosis. The physician who can tell what is the matter as soon 
as he looks at a patient, is, in a large measure, responsible for 
the great distrust of medical skill existing at this time in the 
minds of the public. 

In the psychical cases, the environments must be considered; 
for instance, a child living among, and constantly associating 
with criminals, is not necessarily insane or hysterical, because 
it is very deceitful, shrewd, and generally immoral. 

In differentiating from any organic disease, it will always be 
found that some essential feature of the organic disease is ab- 
sent ; it may be in the mode of onset, previous history, the 
course, or the present symptoms. To determine this requires 
careful, close physical examination, and a knowledge of those 
things absolutely essential to the disease that is resembled. 
Thus, in a hystero-epileptic attack, there is not that form of 
muscle action indicative of absolute loss of volition, or of 
consciousness. Close observation will show that the various 



726 THE DISEASES OF CHILDREN. 

contractions are, at least in part, directed by the mind of the 
patient. In the hysterical hip-joint disease, the position of 
the foot will not be right ; the pain on moving the joint in the 
socket, will not be produced under the manipulations that 
must produce pain if the joint is actually the seat of the 
disease. 

The differentiation between hysterical and other convulsive 
attacks is sometimes exceedingly difficult. The hysterical at- 
tack may resemble the Jacksonian epilepsy so closely as to 
make a diagnosis impossible for weeks, or even months. There 
is no doubt that a certain percentage of the cures, following 
operations for the Jacksonian, are in purely hysterical cases. 
In the hysterical, there is no collateral evidence of localized 
lesions, nothing in the history to make a localized cerebral dis- 
order probable. In hysterical attacks, each attack is usually 
the result of some emotional disturbance. There is apt to be 
palpitation, malaise, choking, or bilateral-foot aura. The onset 
is apt to be gradual ; the scream likely to be during the course 
of the convulsion. The convulsive actions are usually in the 
form of rigidity or struggling and throwing the limbs and head 
about. The biting is commonly of the lips, hands, or more 
often of other people and things. Micturition and defecation 
almost never occur. Talking is quite frequent. The duration 
is frequently of for half an hour, or for several hours. The need 
of restraint seems to be more for the purpose of controlling 
violence than of preventing accident. The termination may 
be spontaneous or artificial. 

Prognosis. — The prognosis in hysteria in children is, or rather 
may be, favorable in every case, where it is possible to secure 
proper treatment. There are likely to be recurrences from 
time to time. 

Treatment. — The treatment may be classed as preventive 
and curative. The preventive treatment, I think, is sufficiently 
indicated under the causes. The nervous child should always 
be kept from emotional influences as much as possible. The 
first step in curative treatment should always depend on the 
thorough and complete examination that has been made. Any 
and every possible source or reflex irritation should be cured 
or removed ; following this, discipline must be maintained, not 
harsh, but firm and steady. The right kind of sympathy is 
difficult to obtain. There is in nearly every hysteric, as a 
motive for the symptoms, a craving for sympathy. In a very 
large number of cases, I am sure, the patient is not conscious 
of this. In many cases the motive power is the procuring of a 
desired object, but these cases are in the minority, I believe. 
How to secure sympathy that will not feed this abnormal 



HTSTERIA. 727 

craving, and at the same time will not cause the patient to feel 
that no one has any interest in him or her, is a matter for care- 
ful consideration and tact in each individual case. In many 
instances it is absolutely necessary, even with quite small chil- 
dren, to take them from home into new environments, and 
sometimes even away from their own family, and place them 
under the care of entire strangers. 

The confidence of the patient must be secured. This is 
often a matter of some considerable time, and it can never be 
accomplished by deceiving the patient, nor will it usually come 
from positive statements alone. The physician must use the 
psychical force of which he is possessed, to influence and mold 
the inner consciousness and thought of the patient. This sug- 
gests hypnotism, a subject I do not propose to discuss here. 
I will simply say that many hysterias have been cured by it. 

The inner consciousness of the patient must in some way be 
convinced that improvement is going on ; telling a patient of 
this kind that it is all imagination is harmful, not beneficial. 
The physician must recognize and feel that hysteria is a disease, 
as much so as any other ailment, and that the cure requires 
study and judgment, as well as tact. 

General massage, and if the patient is thin or anemics, oil of 
some kind in conjunction, will be useful in many cases. 

Electricity is often a valuable agent. Central galvanism or 
general faradism are usually the best, but local treatment to 
specially affected parts may be valuable. 

Baths of various kinds, hot or cold, may be of service in reg- 
ulating the circulation, may assist in elimination and in build- 
ing the tissues, and in this way improve the nutrition. Great 
caution must be used not to frighten children in giving the 
baths, or other forms of treatment. Douches, shower baths, 
and salt baths may be of service. 

Much has been said of hysterogenic points in hystero- 
epilepsy. In my experience, prompt cessation of a fit has 
occasionally followed from pressure on the testicles, the 
ovaries, or the inframammary regions, or over the spine, but 
many purely hysterical cases are not relieved at all by this 
measure. 

In many cases where an aura travels up an arm or leg, relief 
is found by pressure over a nerve trunk with the thumb 
or a knotted ligature before the aura has passed that point. 
Hypodermic injections of water, or medicated, are often bene- 
ficial. 

It will frequently be found that it is better not to give too 
much attention to apparent local troubles, rather make the 
treatment general. The child's mind should be directed into 



728 THE DISEASES OF CHILDREN. 

other channels, rather than allowed to dwell on itself and its 
ailments. 

It will be, sometimes advisable to give a new direction to the 
study, reading and amusement, even where there seems to be 
no good reason other than that the patient is anxious to pur- 
sue its own selected line. 

Remedies in hysteria are to be selected with great care, and 
can be given with great confidence, but not if the general man- 
agement of the case is neglected. 

The bromides and other narcotics and hypnotics should never 
be used, they are positively harmful. The old fashioned drug, 
asafetida, in crude doses, may in some instances be of great 
service. It would be impossible to give anything approaching 
a systematic guide, to the selection of the indicated remedy in 
the space at my disposal. There is scarcely a remedy in the 
materia medica that may not be indicated. The remedies that 
have been most commonly useful in my hands in the hysterias 
of children are : aconite, animoniuDi carb., apis mel., asafetida^ 
belladonna, calcaria carb., calcaria phos., cantharis, causticum, 
chamojnilla, cicuta, coniitni, gelsemium, hyoscyanius, ignatia kali 
phos., lycopodium, magnesia phos., moschus, nox moschata, 7iux 
vom.y platinum, sanguinaria, sticta pulmonaria^ stramonium^ 
sulphur and zincum phos. 



CHAPTER IX. 

DISORDERS OF SLEEP. 

The child must sleep plentifully if it is to grow and develop 
as it should. During the first three months it should sleep 
from sixteen to eighteen hours every day. From this to two 
years of age from fourteen to sixteen hours, and then, to ten 
years of age, from ten to twelve hours. Insistence on regular, 
quiet sleep, is of the greatest importance. 

The habit, so common, of taking children to places of amuse- 
ment, or out visiting in the evening is very bad. The digestion 
and nutrition cannot but be interfered with. The child should 
always sleep alone and should be, early, taught to go to bed 
and to sleep alone in spite of light or ordinary noises. If 
proper care is taken a child will not waken from any slight 
cause. The perfectly healthy, well-trained child will sleep in 
spite of unfavorable environments. The sleeping room should 
always have the greatest possible amount of sun during the 
day and plenty of fresh air at night. If a child does not sleep 
soundly and well there is something wrong either with its phys- 
ical condition or its environments. I am fully satisfied the 
wrong is more frequently in the parents or nurses, than any 
where else. 

A parent will claim to love a child and at the same time,, 
solely for self-gratification and self-pride, will, on every possi- 
ble occasion show off all the child's accomplishments to every 
one with whom it comes in contact. Mothers will waken a 
month old babe to show some friend what pretty eyes it has. 
Simply because they want to attend a party or go somewhere^ 
for their own pleasure, parents will take the child along because 
they do not want to remain at home and cannot leave the child 
alone, and thus break up the regular, habitual hours of sleep. 
Other parents will give the entire charge of the child to a hired 
attendant, not taking any particular pains to kno\A^ whether 
such attendant is competent or not. 

Regularity of hours in going to sleep and waking are of the 
first importance. Habit is a great master. If a child is kept 
fretted and worried, or excited in any way, the greater part of 

(729) 



730 THE DISEASES OF CHILDREN' 

the day, it cannot get a good restful sleep, such as is essential 
to its well being at night. 

If the environments are satisfactory and sleep is interfered 
with, the physician must find some cause, for a cause always 
exists other than perversity on the part of the child. Various 
diseases interfere with sleep. In such instances it is simply an 
accompaniment and is to be considered in the treatment of 
that disease. 

Restless, fitful sleep, or wakefulness is probably more fre- 
quently due to digestive disturbances than to any other cause. 
This may be the result of some immediate indiscretion in diet, 
or to regular, continued indiscretion. 

Constipation is not at all infrequent in children, and often 
causes derangement of sleep. 

Various reflex irritations will derange the circulation, inter- 
fere with normal digestion and nutrition, or produce a general 
nervousness, and, while not sufficient to produce tHe more 
marked disorders, will interfere with the sleep. In many chil- 
dren there is a condition that is best described by the term 
cerebral irritation, a condition in which, without any actual or 
regular derangement of the cerebral circulation, where no name- 
able disease entity can be discovered, the child is unduly ex- 
citable, nervous, peevish, irritable, has more or less headache, 
and is a poor sleeper, is subject to unpleasant dreams, somnam- 
bulism, night terrors, or even a mild form of hystero-epilepsy. 
It would not be justifible to diagnosticate cerebral irritation as an 
entity unless the symptoms have existed for some considerable 
time. In these cases there is always a findable cause, either in 
the training, the environments, the digestive tract, or in some 
reflex irritation. 

In all cases make a thorough and complete examination. 
Various defects in the eye, it must be remembered, are always 
to be thought of when reflex irritations are mentioned. 

Treatment. — In the treatment of these cases, first see that 
the psychical and physical environments are corrected, so far 
as possible, then correct all possible sources of reflex irritation 
and then prescribe your remedies. 

In selecting a remedy take into consideration all the symp- 
toms presented, not those of sleep alone. Never under any 
circumstances use any hypnotic or narcotic to force sleep. 
Always bear in mind that opium in any form is not well borne 
by young children, and is always dangerous. 

The remedies that have, in my hands been most frequently 
indicated are: aconite, belladonna, calcaria carb., chamomilla, 
coffea crnda, cypripedhim, cimicifiiga, gelsemiuni, Jiyoscyaviiis, 
lycopodium, opium 6x tojoc, mix vom., and stramonium. 



DISORDERS OF SLEEP. 731 

Night Terrors deserve special mention. It is important in 
that it indicates, if recurring at all frequently, a marked nervous 
irritability that may lead to more serious disturbance. It has, 
and properly so, been considered as belonging to the nocturnal 
hysterias, and yet as it seems often to be the only manifestation 
of trouble, it is accorded a distinct recognition. It is in some 
cases, without doubt, a precursor of epilepsy or of recurrent 
convulsions, not frequently enough, however, to warrant a pre- 
diction of the graver condition from this symptom alone. 

It is occasionally an accompaniment of cerebral organic dis- 
ease. It may be the result of reflex irritation, or of emotional 
excitement. It is probably more frequently the result of 
digestive or intestinal disturbance. 

The anemic, scrofulous, tubercular and rachitic child is more 
likely to be subject to these attacks than the strong and robust. 
The child of fine, sensitive, nervous organization, and the very 
excitable and enthusiastic child, even if fairly strong and 
well-nourished, may be considered as predisposed. Obstruc- 
tion in the nasal passages from catarrh or foreign growths, 
obstructions in the throat from foreign growths, or enlarged 
tonsils, are quite frequently causes. They usually begin be- 
tween the first and second dentition, very rarely later than the 
eighth year. 

The attack is more likely to come on early in the night, 
within three or four hours after going to sleep. The child 
wakens screaming and showing every evidence of being very 
much frightened, may jump up in, or out of, the bed, and try 
to fight off some imaginary thing, or throw the hands around 
wildly in all directions. At times the child will indicate, by 
word or action, the special cause for fright, but more frequently 
it is simply a general fright. The child evidently is not con- 
scious of its surroundings, does not know parents or friends 
that may be with it. In a short time usually from fifteen to 
twenty minutes, it may begin to recognize persons and objects 
about, gradually becomes calm, and then goes to sleep and is 
quiet until morning. There are, sometimes more than one at- 
tack in the night, but this is not frequent. The next morning 
as a rule there is no recollection of the occurrence, occasionally 
there is, although there is a great disinclination to talk about it 
or to hear it referred to. 

The treatment must be first directed to securing good, 
healthy surroundings and general quieting influences. Any 
and all possible sources of reflex irritation should be removed 
promptly. Special attention to the digestive tract should be 
given. I believe more cases have recovered while under my 
care, from the administration of pepsin than from any other 



732 THE DISEASES OF CHILDREN. 

single line of treatment. It will be frequently necessary to 
circumcise or to remove the tonsils, or some foreign growth 
from the nose or throat. In the anemic cases thorough nour- 
ishment is the essential element of treatment. 

My chief remedies, for the night terrors themselves, are : 
belladonna^ hyoscyamus, nux vom., gelsemium, calcaria carb.^ 
kali phos., cicuta virosa^ ignatia^ santonin and stramomium. I 
never use the bromides or opiates for these cases. 



CHAPTER X. 

HEADACHES IN CHILDREN. 

Children never have headache unless something is the 
matter with them. They frequently complain of headache in 
the way of imitation or feign headache for the purpose of ob- 
taining sympathy, or their own way. It requires very little 
observation and acumen to detect these cases. 

Headache may be an accompaniment of nearly any disease, 
acute or chronic. There is a distinct nervous headache, known 
as a bilious headache, as megrim or migraine. This form is 
recurrent at regular or irregular intervals, and without appar- 
ent immediate cause. The pain is very severe, may be present 
on waking in the morning, grow steadily worse for a time, and 
then gradually or suddenly subside, very frequently during 
sleep. It may come on at any time of day, gradually grow 
more severe, and then gradually or suddenly subside. It may 
be unilateral or bilateral. It may appear first on one side and 
then on the opposite side, or it may sometimes occur on one 
side in one attack and on the opposite side in another attack. 
Occasionally the attacks will alternate on the opposite sides of 
the head regularly. In a large proportion of the cases nausea 
and vomiting will be associated with the pain at some time 
during the attack. In some instances the pain subsides in- 
stantly whenever emesis occurs. In these cases I can see no 
reason why emesis should not be artificially produced promptly, 
but this is only justifiable in the few cases of this special type. 

Disorders of digestion, or any other source of reflex irritation 
may cause a tendency to frequent and more or less severe 
headache. 

The child that is brought up in an unnatural, forced atmos- 
phere, or is kept too constantly in doors, or is kept too clean, 
who does not get sufficient good, pure out-door air and physical 
exercise, who is a constant recipient of don'ts, or who lives in 
an irritable, excitable atmosphere, is likely to have more or less 
headache. 

Kindergartens and early school life may, by causing too close 
mental activity in an unprepared brain, be the cause of more 
or less constant headache. In older children too close confine- 
ment to study is a common source of headache. 

(733) 



734 THE DISEASES OF CHILDREN. 

In this connection the eyes must be specially mentioned, as 
they are the cause of many of the nervous and of all other forms 
of headache. Uremic poisoning is often the cause of either the 
severer or milder form. 

When called to a case in which headache is the one main 
symptom, and is of frequent occurrence, examine carefully till 
you find the cause and then treat that. If, after diligent and 
intelligent search, you are unable to find any cause there is 
but one road to a cure, and while it requires very close study, 
and time it will prove very satisfactory. Take your materia 
medica and find the indicated remedy. I purposely refrain 
from mentioning any special remedies, in this connection, for 
the reason that any predilection toward special headache rem- 
edies will interfere more with success than it will help. My 
own plan is to go to my materia m,edica, in each case, as nearly 
as possible without prejudice in favor of any remedy or group 
of remedies. 



CHAPTER XL 

CONGESTION OF THE BRAIN. 

Congestion of the brain is a condition in which there is an 
increased quantity of blood in the brain capillaries. It is a 
condition much more frequently met with in children than in 
adults. This is easily accounted for b)^ the greater susceptibil- 
ity of the child to both mental and physical impressions, and 
consequent greater liability to circulatory disturbances. 

Congestion of the brain may be a primary disturbance, but 
is more often an accompaniment to other diseases. This is 
especially true of children, for disorders, which in the adult 
produce no appreciable brain disturbances, may cause grave 
and alarming conditions in the child. As stated, congestion of 
the brain is an increase in the amount of blood in the brain 
capillaries, and since this capillary hyperemia is the cause of 
the functional disturbance of the brain, it constitutes the chief 
pathological feature of cerebral congestion. 

Congestion of the brain may be active or passive. It is ac- 
tive when, through arterial distention or dilatation, brought 
about by causes acting directly upon the brain, or from those 
operating directly upon the heart, arterial blood is rapidly 
flowing through the capillaries. It is passive when, by some 
obstruction in the course of the circulation, or when, on account 
of a feebly acting heart, blood is permitted to move but slowly 
through the capillaries, and consequently is largely venous. 

The capillaries are not visible to the naked eye, but viewed 
with the microscope, are seen to be much distended, often to 
double their natural size. There is a deeper tint to the gray 
substance, and an increase in the number and size of red points 
on section of the white matter. In active congestion, there is 
an excess of arterial blood in the brain and its membranes, and 
the arteries are distended and filled to their minutest branches. 
In passive congestion,^ the veins and sinuses are engorged with 
blood. The vessels in the membranes in active congestion are 
bright red ; in passive congestion, they are dark, or of a bluish 
tint. In either condition, if the congestion continues long 
enough, other changes take place. If the capillary distention 
is great, there may be rupture and extravasation over larger or 

(735) 



736 THE DISEASES OF CHILDREN. 

smaller areas, or the distention may be relieved by exudation 
of serum into the pia mater. 

Symptoms. — The symptoms of active congestion of the brain 
are great dryness of, and heat in the head, throbbing of the 
carotids, restlessness and peevishness, especially on being dis- 
turbed, and jerking and twitching of the limbs. There will be 
severe throbbing pain in the head, and if the fontanels are 
still open, they will be distended and throb visibly. In passive 
congestion, many of the symptoms are the same as those of 
the active form. The irritability on being disturbed, the stupor, 
and the twitching are common to both conditions. In the pas- 
sive form, there are sometimes marked general convulsions. 
In passive congestion, the heat of the surface of the body, the 
flushed face and the injected eyes are not present. The sur- 
face may even be cool or bathed in considerable perspiration. 
The throbbing of the fontanels is markedly absent, and the 
distention of the same is not noticeable until later, when serious 
effusion has taken place. 

Etiology. — The causes that produce active congestion of the 
brain in children are numerous. The circulation of the sensi- 
tive, undeveloped brain of infancy and childhood is easily dis- 
turbed. Strong mental emotions, sudden fright, great grief, 
excessive delight, and indiscretions or irregularity of diet may 
operate as causes of cerebral congestion in children. Heredity 
plays an important part in predisposing children to cerebral 
congestion, more particularly the active form. Any form of 
dissipation, hysteria, insanity, and such diseases as tend to pro- 
duce neuropathic children, tubercular diseases especially, will 
predispose the child to cerebral congestion. 

Children with active, precocious minds and large brains, 
are strongly inclined to cerebral congestion on slight provoca- 
tion. Rapid or difficult dentition may also predispose to this 
trouble. 

The various inflammatory diseases and febrile affections, es- 
pecially in their first stages, are often attended by severe con- 
gestion of the brain. The elevation of the anterior fontanel, so 
markedly characteristic of active congestion of the brain in the 
infant, is often unusually prominent in the first stages of fevers 
and inflammations, and in such cases cerebral hyperemia is ob- 
viously present. This fact leads to the natural inference that 
in the first stages of the febrile and inflammatory affections, 
when brain symptoms are present, there is often an actual, ac- 
tive cerebral congestion, and not merely a functional disturb- 
ance of the brain through sympathetic nervous connection. 
The acute inflammations of the mucous membranes are most 
likely to be attended by cerebral congestion. Severe bron 



^W?!^ 



CONGESTION OF THE BRAIN. 737 

chitis, colitis, enterocolitis, and dysentery, with a sudden onset 
and intense febrile excitement, are frequently accompanied in 
this first stage by active congestion of the brain. Extra activ- 
ity of the heart from any cause, functional or organic, may be 
a cause of active congestion. Traumatic violence, as a blow or 
a fall upon the head, must not be lost sight of as a cause in this 
affection, nor the exposure to excessive heat, the former being 
a frequent cause, and the latter occasionally explaining an 
otherwise unaccountable origin. 

The causes of passive congestion differ very greatly from 
those of the active form. It is due to an impediment in the 
return of blood from the brain, or to a weak and slow action of 
the heart. Prolonged and difficult labor will at times result in 
the birth of an infant presenting the most marked symptoms 
of passive congestion of the brain, such as stupor, twitching of 
the limbs, and even convulsions. This condition may gradu- 
ally disappear, unless hemorrhage be coincident with the 
congestion. 

One of the most frequent causes is found in strumous or tu- 
bercular children, where enlarged glands, by pressure on vena 
innominata, or descending vena cava, obstruct the return of 
blood from the brain. If a child suffering with advanced tuber- 
culosis of the bronchial or pulmonary type exhibits brain symp- 
toms, such as rolling of the head, boring the head into the 
pillow, with possibly slight irritability of the stomach, passive 
congestion is the probable cerebral condition, and in such cases 
extremely enlarged bronchial glands pressing upon the above- 
mentioned vessels have frequently been revealed by the au- 
topsy. Whooping cough, which so often produces extravasa- 
tion into the conjunctiva, and even under the tissues surround- 
ing the eye, may sufficiently interfere with the return circulation 
from the brain as to cause passive hyperemia. Malarial diseases, 
especially the intermittent and remittent types, where the cold 
stage is profound and prolonged, may be attended by serious, 
and occasionally fatal congestion of the brain and its membranes. 
School children who are exceedingly studious, and great read- 
ers, and who take comparatively little physical exercise, are apt 
to suffer from passive congestion of the brain. If the child 
hangs with the head down for any considerable time, it 
will have a passive cerebral hyperemia, which is occasionally 
serious. It is occasionally the result of an accidental pressure 
about the neck. Foul air or noxious gases are often productive 
of this form of congestion. Asphyxiation is nearly always 
accompanied by passive congestion. Anything that interferes 
with the free action of the lungs and oxygenation of the blood, 
may result in passive congestion. Rheumatism or other 
'". C— 47 



738 THE DISEASES OF CHILDREN. 

diseases interfering with the heart's action so as to diminish its 
force, may cause passive congestion. Active or passive con- 
gestion may either of them be the result of toxic influences. 
Many drugs affect the cerebral circulation. 

Prognosis. — The cause operating to produce the congestion, 
the intensity of the hyperemia, and the promptness with which 
the proper treatment is instituted, largely govern the prognosis 
in this condition. The cases most frequently met, where the 
causes are such as excitement, fatigue, overheating, or indiscre- 
tion in diet, readily respond to prompt and proper treatment. 
Where the condition is secondary to other acute diseases or 
constitutional disturbances, the prognosis of the brain trouble 
depends upon that of the producing disease. 

The prognosis in passive congestion, depending upon ob- 
struction to the circulation of the brain, will be governed by 
the possibility of the removal of the obstruction. In those 
cases resulting from continuous mental activity, the prognosis 
may be always favorable. In those cases resulting from foul 
air and noxious gases, if coma is not present, the prognosis is 
favorable. When caused by lung or heart conditions, the prog- 
nosis will be that of those conditions. Cerebral congestions 
resulting from overheating, while often cured, are always to be 
considered serious. 

If congestion of the brain is not recognized and controlled 
early, it is likely to pass rapidly on to a more serious condition 
of extravasation or effusion, with concomitant coma and possi- 
ble death. 

Treatment, — The principal object to be accomplished in the 
treatment of cerebral congestion is the diminution of the 
amount of blood in the encephalon. The condition of the 
bowels should be inquired into, and, if necessary, a full enema 
of warm water should be given, or even a brisk saline laxative. 
Stimulating applications should be made to the feet, such as 
mustard or the hot foot-bath. The child's feet and legs may 
be immersed to the hips in hot water containing mustard, al- 
ways using at the same time cold applications to the head, but 
never ice. If you have reason to suspect the presence of undi- 
gested food in the stomach, do not hesitate to give a quickly 
acting emetic. The application of a moderately active mus- 
tard draught to the cervical spine may follow the foregoing 
measures with advantage, still continuing the cold applications 
to the head. These are measures accessory to drug therapeu- 
tics, which are of the greatest importance, and should be made 
ase of as early in the case as possible. The head and shoulders 
of the child should be slightly elevated, and perfect quiet main- 
tained in all its surroundings. Never allow the child to be 



CONGESTION OF THE BRAIN. 739 

carried about, or rocked in a cradle, or jolted or swayed back 
and forth in the lap of the attendant. 

The medicines most often indicated in the early stages of 
this affection, and upon which the greatest reliance may be 
placed, are comparatively few. Aconite ^belladonna, gels emiunty 
and veratrum viride may be said to constitute our chief and 
almost whole drug resource in the early treatment of this 
disease. 

Aco7iite. — Early in the case, great heat, dry skin ; full, strong 
pulse ; high temperature ; anxiety and restlessness. 

Bellado7ina. — Intense restlessness ; fierce delirium or incohe- 
rent muttering; red, bloated face; injected conjunctiva; great 
sensitiveness to light and noise ; throbbing of the carotids 
and temporal vessels. A perfect picture of extremely active 
congestion. 

Gelsemhtm. — Heaviness of the head ; dullness of mind and 
perception. Child becomes drowsy, comatose and convulsive. 

Veratrum viride. — Great rapidity of the pulse is the leading 
indication for this drug, and especially if with this symptom 
convulsions threaten or are present. It will be more often in- 
dicated in cerebral congestion than any or all other remedies. 
It should be given low and in frequently repeated doses until 
some diminution in the pulse rate is observed, when the size 
and frequency of the dose maybe diminished. I consider it of 
great importance when veratrum viride \s being given in appre- 
ciable doses, that the physician give it himself, and with the 
finger on the pulse of the patient, carefully watch its effect until 
the desired result is obtained, and the dose is reduced to a safer 
limit. 

The causes operating to produce the congestion will often 
govern the selection of the drug as much as the symptoms pre- 
sented. Those cases due to gastric or enteric disturbances will 
require such remedies as Bryonia, nux vomica, mercurius, pul^ 
satilla, arsenicum, or calcarea carb. If caused by overheating, 
belladonna, glo7ioin or veratrum vir. 

When the result of a fall, blow, or concussion, arnica, bella- 
domta, bryonia, hypericum. 

If due to excitement, aconite, belladonna, ignatia, chamomillay 
or perhaps bryonia or nux vomica. 

When complicating dentition, aconite, chamomilla or 
gelsemium. 

The disposition to congestion of the brain is often controlled 
by such remedies as calcarea, hepar, silicia and sulphur. 

The remedy par excellence for school children who show a 
tendency to brain trouble, is calcarea phos. 

When congestion is due to a feebly acting heart, the drugs 



740 THE DISEASES OF CHILDREN. 

which will increase the force of the heart, in connection with 
such as have a general tonic action, will be useful. Among 
them are digitalis, glo7ioin, hydrocyanic acid, cactus and strychnia. 

In those cases of passive congestion, where the pressure of 
growths or enlarged glands operate as causes of circulatory 
obstruction, help must be found, if at all, through the drugs 
known to have the power of absorbing such products, or through 
surgical measures. 

If congestion of the brain is not relieved promptly, especially 
in acute attacks, effusion or extravasation will take place, and 
other pathological conditions supervene, after which congestion 
is no longer the prominent condition, and the disease would 
probably be called by another name. 



CHAPTER XII. 

MENINGITIS. 

Definition. — Meningitis is an inflammation of the covering of 
the brain — the pia mater — which may be general or limited to 
the convexity of the brain or to its base. It may be traumatic 
in its origin, idiopathic or symptomatic ; simple or tubercular. 
Until early in the present century, all inflammations of the brain, 
both acute and chronic, were included in the general term hy- 
drocephalus. The latter term is now restricted to those cases 
of chronic character, in which there is a gradual effusion of se- 
rous fluid into the ventricles of the brain, causing them to 
become more or less distended and the head enlarged — a true 
dropsy of the brain. 

A condition called ''spurious hydrocephalus'' is met with not 
infrequently in connection with the wasting diseases of child- 
hood, especially during the later stages of inflammatory diar- 
rhea. 

The symptoms of this form of hydrocephalus are those of 
great exhaustion, pinched features, livid complexion, drowsi- 
ness, which gradually deepens into coma, rapid intermittent 
pulse, irregular, sighing respiration, subnormal temperature, 
and sunken fontanel. 

Simple Meningitis. — This form of meningeal inflammation 
may be divided, according to its causes, into idiopathic and 
traumatic — the former being much more common than the lat- 
ter. All forms of meningitis are more common in childhood 
than in adult life. It is much more frequently met with among 
males than among females. It is apt to occur in the course of 
any and all the acute febrile diseases, such as measles, scarla- 
tina, and rheumatic fever. It may occur as a complication in 
erysipelas of the head and face, or in the course of pneumonia 
or pleuro-pneumonia. 

It is common among cachectic subjects, independently of 
previous acute affections. Diseases of the ear and nose are 
quite prone to extend their baneful influences to the brain and 
eventuate in acute simple meningitis. Excessive mental activ- 
ity at school is undoubtedly responsible for many cases, as is 
prolonged exposure to the direct rays of the sun. 

(741) 



742 THE DISEASES OF CHILDREN. 

The traumatic variety is met with after injuries of the head, 
as from blows, even when the blows have not been severe 
enough to cause an external wound or fracture of any of the 
bones of the skull. 

Simple idiopathic meningitis is usually due to an extension 
of some inflammatory process remote from the brain, and is 
therefore, a secondary disease, the traumatic variety alone being 
primary. 

In post-viortem examinations of children dead of meningitis, 
the brain is usually found covered with a layer of yellowish or 
green pus, and the same kind of substance may be found also in 
the ventricles. For this reason the disease is frequently known 
as *' suppurative meningitis." 

In prolonged cases — it sometimes lasts a month — the pus 
may be found to extend down about the cord in quantity, 
where it will mostly appear on the posterior aspect, having evi- 
dently gravitated to that position. There is practically no dif- 
ference between meningitis of the brain and that of the cord. 

The membrane affected is one and the same, and disease of 
the membranes of the brain run with perfect facility along 
those of the cord. There is, therefore, no occasion for a sepa- 
rate consideration of that form of meningitis in which both 
brain and cord are involved, and known as ''cerebro-spinal 
meningitis." 

Symptoms. — The symptoms of meningitis are often indefi- 
nite. Hebetude or coma will not infrequently occur in chil- 
dren, seemingly of the most alarming nature, but which will 
disappear in a day or two, being apparently a reflex of some 
indigestion or vasomotor condition. Then again the acute 
febrile affections of children, such as the pulmonary, enteric 
and miasmatic diseases, and the exanthemata will produce grave 
conditions of hebetude, coma or delirium, and it will often be 
a matter of great nicety to determine how much is reflex from 
the primary disease, and how much may be due to actual im- 
plication of the cerebrum or its membranes. 

The symptoms are apt to vary somewhat with the age of the 
child. In young infants there is a tendency to collapse, rest- 
lessness, swelling of the head, enlargement of the veins of the 
surface, and retraction of the neck. 

In older children there is apt to be more fever and more defi- 
nite evidences of meningitis in headache, vomiting, irregularity 
of pulse, and squint. 

Whatever the age, the face is pale and pinched, the head is 
retracted, the bowels confined and food is taken badly. Among 
the early symptoms cephalalgia is usually pronounced, and is of 
an intermittent character. This cephalalgia may be general or 



SIMPLE MENINGITIS. 743 

localized in some particular region of the head, and if the child 
is old enough to describe his sensations, it is complained of 
again and again ; if too young to talk, the pain is indicated by 
cries, by application of the hands to the head, or by other un- 
mistakable signs. The intensity of the pain in the head varies 
greatly in different subjects, and in some cases it may be nearly 
absent, or it may come on at a later date. Insomnia is gener- 
ally present from the commencement of the attack. Delirium 
of various grades of intensity is usually present, sometimes of 
a mild and quiet type, mere loquaciousness ; at others it is fu- 
rious, and attended with screams and kicks. 

In some cases delirium is replaced by a semi-comatose con- 
dition which gradually deepens into actual coma. Nausea and 
vomiting, and also convulsions, either general or local, may be 
met with in the early stages of the disease, and also as initial 
symptoms. 

There is often intolerance of light and loud sounds, more or 
less general pyrexia, with heat of head, rapid pulse and irregular 
respiration. The tongue is furred, and often thickly coated. 
The bowels are constipated. 

As the disease progresses we are pretty sure to have convul- 
sions or spasms, often of the tonic order, affecting the muscles 
of the head and neck, which are frequently drawn backwards, 
or one or both arms ; or a condition of trismus may exist. The 
eyes are sometimes drawn upwards, and occasionally inwards. 
The pupils may be at first contracted, but later are widely di- 
lated and insensitive. Inequality of the pupils is quite com- 
mon. The conjunctiva are often injected. The abdomen is 
retracted and hollow. DifTficulty of deglutition is frequently well 
marked toward the end. As soon as the stupor is pronounced, 
there is incontinence of feces and urine. The temperature is 
at times high, but subject to fluctuations — marked irregularity 
of temperature being quite typical. The skin is generally hot 
and dry, though occasionally there may be copious sweats. 

Prognosis. — A large percentage of deaths take place within 
the first week of acute meningitis ; a much smaller number sur- 
vive till the end of the second week, while a few exceptional 
cases do not succumb till into the fourth week. The disease is 
one of great gravity ; and while it is difficult to say just what 
the percentage of recoveries is, it probably does not exceed ten 
in a hundred cases. 

Diagnosis. — The differentiation of idiopathic from tubercular 
meningitis is attended usually with much difficulty. 

The treatment of both varieties, however, is so similar, that 
an accurate diagnosis is not altogether essential. 

The fact that an inflammation of the meninges is present or 



744 THE DISEASES OF CHILDREN. 

threatened, is a matter for the gravest consideration. A few 
points will aid in reaching a decision as to which form we are 
dealing with. 

In the first place, idiopathic meningitis is far more rare than 
tubercular, the latter being, unfortunately, all too common. De~ 
lirium is rarely so violent in tubercular as it may be in simple 
meningitis. 

Retraction of the head is also neither so marked nor so fre- 
quent in the tubercular variety. 

The temperature is usually higher in simple than in tuber- 
cular meningitis — rarely rising over 103° Fahr. in the latter 
form. In tubercular meningitis, the two sexes fall victims in 
about equal numbers, while in simple meningitis two out of 
three cases are likely to be males. In children and infants re- 
traction of the neck should always excite apprehension, and 
any rigidity of the neck or pain in movement. The other signs 
of meningitis must then be sought for, such as rigidity of mus- 
cles elsewhere, evidence of pain in the head, swelling of the 
head, distention of the veins of the scalp, vomiting without ap- 
parent cause, retraction of the abdomen, constipation, irregu- 
larity of pulse, sighing respiration, a tendency to reddening of 
the skin after slight friction (tache cercbrale), and the state of 
the fundus oculi. 

The previous state of health should be inquired into — the 
prior existence of measles, scarlet fever, sore throat, earache, 
etc. In meningitis no one symptom is infallible, and the whole 
group of symptoms will often leave us in temporary doubt. 
The most reliable, however, are retracted head, fever, causeless 
vomiting, irregularity of pulse, and muscular rigidity or 
weakness. 

Treatment. — To avoid needless repetition, the reader is re- 
ferred for treatment to the next section on Tubercular Menin- 
gitis, where the whole subject of remedial measures will be 
discussed. 

Tubercular Meningitis. — Tubercular or " granular" men- 
ingitis differs from simple or idiopathic meningitis in having its 
remote origin in a general tuberculous condition of the subject 
— in other words, it is tuberculosis, plus meningeal inflamma- 
tion. Tubercular meningitis is not an independent affection, 
but constitutes one important phase of " a many-sided general 
disease commonly known as acute tuberculosis, and marked 
anatomically by the presence of ' gray granulations 'within the 
the thorax and abdomen, as well as in the membranes of the 
brain. In certain rare cases death takes place from granular 
meningitis before the anatomical marks of the general disease 



TUBERCULAR MENINGITIS. 745 

have had time to develop within the chest or abdomen. More fre- 
quently, however, the manifestations of the general disease are 
already developed in one or other, or in both of these situa- 
tions, at the time that they reveal themselves also on the side 
of the brain. In the latter, and by far the most common class 
of cases, the symptoms met with will be in part those of the 
general affection, and in part (but in a predominant degree) 
those due to that implication of the brain and its membranes 
with which we are specially concerned." See preceding section 
on Idiopathic Meningitis. 

Etiology. — From what has just been said, it will be seen that 
the etiology of tubercular meningitis resolves itself into the 
etiology of the general disease — acute tuberculosis — of which it 
forms a part, and the reader is referred to the chapter on this 
affection, where the subject of etiology is fully discussed. 

Symptoms. — By some authors the disease w^e are now 
considering is divided into different stages, each with its own 
peculiar symptomatology. But it is only in rare and typical 
cases that such a division can be at all helpful in setting forth 
a picture of the disease. 

To the experienced and watchful physician there are certain 
prodromal symptoms that in many cases are sufficiently pro- 
nounced to attract early attention to the approach of serious 
disorder, and it is in such cases, and in such cases only, that our 
remedies will be found of value. These early symptoms are 
gradual — sometimes rapid — emaciation, restlessness, impaired 
digestion. At night the child grinds his teeth, has night terrors, 
wakens frightened, or has strange fancies and delusions. In 
some cases there is a newly-developed perverseness, so that a 
naturally tractable child becomes unmanageable and willful, or 
is irritable and peevish ; in other cases, the child becomes taci- 
turn, sad and apathetic, indisposed to play ; the appetite is 
fickle, with craving for strange and unsuitable things. One of 
the most characteristic symptoms of this early stage is w^hen 
the child will waken with a scream, or will sit up in bed and 
shriek. Even now there may be headache, though this usually 
forms a prominent symptom later on in the progress of the 
disease. There may be some squinting or twitching of the 
facial muscles. Many or all of these symptoms are often so 
slight that they pass unnoticed till too late; but all of them are 
significant and not one of them should be allowed to go un- 
heeded. 

There is often a remission of symptoms during this early 
stage, so that physicians and friends think that the child has 
recovered his health ; but this is generally delusive, and a little 
later the same symptoms return with increased violence. Head- 



746 THE DISEASES OF CHILDREN. 

ache will now be complained of, or indicated by sign language ; 
a convulsion is likely to occur, or the child lies in a comatose 
state, with pupils unequally dilated, pulse rapid and irregular, 
respirations sighing, or of the cheyne-stokes variety. The child 
complains of light and sound ; the tongue is dry, or has a thick, 
moist coating, with red edges. During sleep he occasionally 
utters a sharp, shrill cry without awakening — the cri encepha- 
lique — so characteristic of the disease. 

When these symptoms are present, we have a typical case of 
tubercular meningitis in the first stage. But they are inclined 
to remit and remit again, until sometimes weeks and even 
months go by before the critical stage is reached. More often 
the case goes on gradually from bad to worse, unless the 
nature of the disease is early recognized and remedies are 
brought to bear upon it. The apathy increases ; the eyes are 
less sensitive to light ; the constipation is obstinate. 

After a variable period the child shows signs of disturbances 
of nerve centers, due to increased exudation and pressure at 
the base of the brain. This is manifested by strabismus, twitch- 
ing of facial muscles, paralysis or coma. If the anterior fonta- 
nel is still open, it is found bulging, and the scalp covering it 
is tense from pressure of the effusion beneath. The fever in 
tubercular meningitis is not usually high. It may not exceed 
ioo° Fahr. until towards the fatal end. The pulse is often be- 
low the normal in frequency, and in nearly all cases is extremely 
irregular. In the latter stages of the disease, frequent and long- 
continued convulsive seizures are apt to occur, and death may 
take place during or immediately after one of these attacks. 

The patient may take the food which is offered up to the 
last, though at other times, or in other cases, there seems to be 
an actual inability to swallow it, even when it is placed in the 
mouth, owing to the paralysis of the muscles of the tongue and 
pharynx. 

Inclination to remit in all stages is a characteristic of the dis- 
ease. Unequal dilation of pupils may be said to be considered 
a reliable symptom of beginning trouble, and should attract 
our attention and call for prompt action. The irritation and 
change in temperature, with restlessness, crying out in sleep and 
sudden vomiting without nausea, are constant symptoms of the 
premonitory stage and should cause alarm. 

The irregular pulse and respiration are sure indications of 
progress. The temperature is of very little help in diagnosis. 
The coated tongue and offensive breath are not infallible, but 
help to make up the case. 

Diagnosis. — Usually the disease offers but little difficulty in 
diagnosis, especially after it is well developed ; although none 



TUBERCULAR MENINGITIS. 747 

of the above symptoms singly are pathognomonic of the dis- 
-ease, still taken as a whole, considering age, antecedents and 
previous health, you have a case not easy to mistake. The 
real trouble is in the very early stages before all symptoms are 
developed. Then it is sometimes difficult to say that it is the 
beginning of brain disease, and yet this is the critical time in 
the disease. A failure to recognize the importance and mean- 
ing of these symptoms will turn the case from possible recovery 
and gratitude of friends to sorrow and death. 

The diseases for which tubercular meningitis is most likely to 
be mistaken are acute simple meningitis, early stage of typhoid 
fever, acute gastro-intestinal disturbances, worms in intestines, 
teething, the hydrocephaloid disease of anemia and cerebro- 
spinal meningitis. 

Acute meningitis is distinguished by its sudden invasion with- 
out prodromatous stage, family history, previous health, inten- 
sity of symptoms and duration, which is much shorter. 

The early period of typhoid resembles meningitis, but the 
coated tongue, diarrhea, enlarged spleen, tympanites, abdom- 
inal tenderness and gurgling, the eruption and the characteris- 
tic temperature curve, will decide the diagnosis. 

Intestinal irritation from worms very closely resembles tuber- 
cular meningitis, and is at first very hard to differentiate, but a 
•close observation of the case, family history and course of the 
attack, high temperature, etc., after careful anal3^sis ought not 
to mislead very long in the case. 

The hydrocephaloid condition spoken of is due to exhaus- 
tion and nervousness, caused by improper nourishment, or im- 
paired digestion, and thus readily excluded. 

Cerebro-spinal meningitis, usually epidemic, is distinguished 
by sudden and acute attack, intensity of symptoms, the erup- 
tion, and prominence of spinal symptoms. There are rare 
cases of cerebral irritation, which closely simulate tubercular 
meningitis. When it is impossible to say just what the mat- 
ter is, sometimes called cerebral congestion or brain fever. 
Such a case runs a longer course with varying symptoms, all 
pointing unmistakably to brain affection, and finally gets 
well. There is nothing to do in such a case but to withhold 
a positive opinion, treat existing conditions as we find them, 
and wait. 

Prognosis. — After the case has passed the prodromal stage 
and progressed to the second with deposit of tubercles, the 
prognosis is very grave, and ev "n should we succeed in staying 
the disease of the brain, it is only to see tuberculosis of the 
lungs develop, or a recurrence of the brain symptoms. 

Pepper, in his work on " Diseases of Children," says: '* That 



748 THE DISEASES OF CHILDREN. 

in almost all cases of reported recovery, the diagnosis was 
erroneous." 

Treatment. — Jahr, in his "Forty Years' Practice," thus 
speaks of his treatment of meningitis : *' This disease, which is 
so apt to run into acute hydrocephalus, is curable by homeo- 
pathic means under almost any circumstances, as long as it still 
retains the form of meningitis and the physician recognizes its 
true character at the outset. Under a proper treatment, all 
danger to life sometimes disappears in forty-eight hours. Only 
no time must be lost with aconite, which has never been of the 
least service to me, but bell. 30th, has at once to be given, a 
teaspoonful of a solution of three globules in water every three 
hours. In most cases a decided improvement will be noticed, 
even after the lapse of only twenty-four hours, and not unfre- 
quently this remedy alone will be found sufficient to completely 
restore the patient's health. If the physician is called too late 
and effusion has already begun to set in, belL will sometimes 
fail us ; in such a case I approve, with the fullest conviction, of 
Wahle's recommendation of bryon. 30th, one globule dry on the 
tongue, and still more of sulph. 30th, administered in the same 
manner, which has altogether rendered me most efficient serv- 
ice in the meningitis of children. It should be remembered 
that sulph. does better after several other remedies have been 
given first, than when the treatment is begun with this agent. 
If the disease has entered upon its third stage, that of fully-de- 
veloped effusion, not much can be expected either of bell, or 
bryon., but, unless it should be too late to do anything for the 
patient, a great deal may yet be accomplished by means of 
helleb., which has likewise been recommended by Wahle ; and 
still more certainly by sulph., and perhaps by apis, which, in 
one case at least, where I had given up all hope of saving the 
little patient, and only gave this remedy as a last resort, had 
such a marked effect that a single dose of sulph. proved after- 
wards sufficient to restore this very sick child to perfect 
health." 

Jahr also says this of cuprum : ** One of the most admirable 
brain remedies, if indicated by spasms in the fingers or toes, 
oppression on the chest, lockjaw. If the cerebral disease de- 
velops itself after suppression of erysipelas or some other erup- 
tion, or even after suppressed catarrh, or during the process of 
dentition, I prefer cuprum to bell." 

The consummate faith in the higher potencies held by the 
early leaders of our school, excites our unbounded admiration. 
There is no question but their faith was well founded. What 
is the trouble now ? Is it because the course of disease 
has changed, or that infantile constitutions have become less 



TUBERCULAR MENIN'GTTIS. 749 

responsive to our attenuated remedies, or have we lost, to some 
extent, the art of accurate prescribing? Certain it is we do 
not, in these degenerate days, get the same results claimed by 
the early prescribers. 

However it be, tubercular meningitis is, at the present day, 
one of the most obstinate and intractable diseases which we 
have to encounter. Cases, however, do recover, and if early 
enough recognized, there is ground for hope that our efforts 
and remedies may prove effectual. In addition to the remedies 
above mentioned, there are others which have seemed to abate 
the incipient disease, or postpone the inevitable result. Among 
these are gelsemium and veratrum viride, but their indications 
are too well known to require repetition here. During the 
comatose stage, opium will be found most serviceable. It has 
no influence over the effusion or thickening, but it relieves the 
venous stasis and arouses the torpid circulation of the brain. 

Zinc is one of the great brain remedies, and is especially use- 
ful when cerebral paralysis seems impending. Dr. Hale prefers 
the phosphid. My own experience has been more with zinciim 
met. and valerianate. Camphora, especially the mono-bromid 
of camphor, is a remedy of great value in the stage or irritation 
before the disease has become fully established. 

Dr. J. Compton Burnett, in his work on " Tuberculosis," 
reports many cases of genuine tubercular meningitis cured with 
tuberculi7ium, in the 30th and higher potencies. 

Dr. T. F. Allen emphasizes the power of kali carb. The 
kali carb. patient may be fat, flabby and exhausted, "but is 
always anemic. He is chilly, never has fever, and is worse 
from exposure — especially to damp air." This is undoubtedly 
a powerful constitutional remedy in the early stage of tubercu- 
lar meningitis, and should not be forgotten. 

Children with meningitis must be kept very quiet and free 
from all excitement. Plenty of fresh air, wholesome, unstim- 
ulating food, regularity of daily life are essential hygienic 
adjuvants. 



CHAPTER XIII. 

HYDROCEPHALUS. 

The amount of fluid in the brain varies under different 
physiological conditions. This is especially true as to age and 
sex. The proportion of water is gradually diminished from 
birth to the age of twenty, after which it gradually increases* 
It is greater in the male than in the female. In adults, the 
proportion of water is greater in the gray matter than in the 
white, while in infants the reverse is the case. Acute disease 
very generally causes an increase in the quantity of water in 
the brain tissue and its cavities. This increase is most marked 
in meningitis and hydrocephalus. 

Hydrocephalus is a condition in which there is a gradual 
accumulation of serous fluid within the cranium ; in most cases 
in the cavities of the ventricles ; quite rarely in the arachnoidal 
space. The effusion produces pressure, expanding the cranial 
contents and the soft, yielding bones, causing the head to en- 
large. Those cases developing the disease after the bony 
structures have become more firm, will exhibit less of this almost 
characteristic deformity. 

It is a disease almost exclusively of infancy and early child- 
hood, and often congenital. Even those cases in which the ex- 
cess of fluid is not appreciable at birth, but makes its appearance 
very soon after, are congenital, since the vice operating to pro- 
duce it, probably exists before birth. 

I shall consider the disease only in its chronic form, congen- 
ital and acquired, leaving the various dropsies of the brain re- 
sulting from meningitis and other acute diseases to be described 
in connection with those affections. 

If the disease is plainly present at the time of birth, it may 
present a serious impediment to delivery, even necessitating 
perforation of the membranes. Under the influence of violent 
uterine contractions, the membranes and scalp have been known 
to give way, and the contents discharged, followed by speedy 
termination of labor. 

The anatomical changes and the clinical course of the disease^ 
in either congenital or acquired hydrocephalus, are not suffi- 
ciently different to necessitate a separate description. It is, 
however, a fairly well-established fact that the cases of congenital 
(750) 



HTDR O CEP HA L US. 751 

hydrocephalus generally present a more extreme development 
of the symptoms than when the disease is acquired. 

The etiology of hydrocephalus is still somewhat uncertain. 
It is often hereditary. Dissipation of all kinds, lead poisoning,, 
syphilis, tuberculosis, and struma in the parents are supposed 
to predispose to the disease. Certain it is that a woman who 
has once given birth to a hydrocephalic child, is very liabk to 
have the succeeding children hydrocephalic. 

A large proportion of the cases of congenital hydrocephalus 
are no doubt due to a low type of inflammation of the lining 
membranes of the ventricles, beginning during fetal life, and 
continuing after birth. There may or may not be post-mortem 
evidences of such inflammation. 

In the acquired cases a frequent cause is obstruction to the 
venous circulation in the brain. This may be caused by pres- 
sure on the return vessels or sinuses, either by tumors, tubercu- 
lar deposits, or cysts, within or without the brain, causing con- 
gestion of the ventricular membranes. Enlarged glands of the 
neck may produce the same result by causing pressure on the 
veins emerging from within the skull. No doubt the most fre- 
quent cause of this disease is some constitutional taint, result- 
ing from an anemic, scrofulous, or rachitic condition, or by 
acute disease in which the blood has become impoverished. 

Morbid A7iatomy. — The alterations in the bony parts of the 
head are marked. Those bones which enter into the formation 
of the dome or arch are most markedly affected. The vertical 
portion of the frontal, the parietal, the squamous portions of 
the temporal, and the upper part of the occipital bone are all 
thinned and often elastic and enlarged much beyond their nat- 
ural area. The size of the sutures and the fontanel are in- 
creased and fluctuation can readily be detected in them. If the 
amount of fluid is large, the frontal bone is tipped forward and 
the direction of the orbits are changed, and the eyes present a 
peculiar appearance, having the lower portion of the cornea 
hidden under the lower lid, while a distinct line of the white 
sclerotic is visible between the upper margin and the upper lid. 

The contour of the head is rarely regular, the sides usually 
bulging, causing the top to appear rather flat. This gives the 
face a peculiar triangular appearance, the triangle being in- 
verted, the top of the head forming the base and the chin the 
apex. The bones at the base of the skull are little affected^ 
though cases have been reported where even here there had 
been decided displacement. In rare cases, where the amount 
of the effusion is not so great, the size of the head is not so ap- 
parent, and the displacements not so marked ; but usually a 
well-marked case will present the appearance described. 



752 THE DISEASES OF CHILDREN. 

In acquired hydrocephalus, making its appearance after the 
bones of the skull are more or less firmly united, the bony de- 
formity of the head may be scarcely perceptible. 

The quantity of the effusion may be anything from normal 
to eight, ten, and even twenty pints. The usual amount, how- 
ever, is not so great, and generally there is present not more 
than a pint or two. In the acquired cases there may be only a 
few ounces. The fluid is clear, or slightly turbid, and of higher 
specific gravity than normal cerebro-spinal fluid. It is alkaline 
in reaction and contains more or less albumin, the percentage 
of albumin, according to Huguenin, being in direct ratio to the 
activity of the inflammation. 

The effect of this effusion in the cavities of the brain is to 
expand them in all directions. The cerebral substance, by be- 
ing compressed between the fluid and the skull, is greatly 
thinned and distended, at times constituting a mere shell. The 
ventricles are in free communication, and the septum lucidum is 
torn or entirely obliterated. The foramen of Monro, and the 
aqueduct between the third and fourth ventricles are distended. 
The structures on the floor suffer equal distortion. The cor- 
pora striata are separated and very much flattened. The crura, 
the corpora quadrigemina, the optic thalami, the optic tracts, the 
cerebellum and the pons are all flattened. The convolutions on 
the surface of the brain are completely obliterated. 

The membranes lining the ventricles often present thickened 
surfaces, and opaque patches, but these evidences of inflamma- 
tion are not always present, even in cases supposed to be of 
inflammatory origin. In the acquired form, where the struct- 
ures are more firm and the fluid less, the linings of the ventri- 
cles show more marked inflammatory changes, the structures 
on the floor being dotted over with small nodules. 

If the fluid is in the arachnoidal space, " external hydroceph- 
alus," it is spread more or less evenly over the surface of the 
brain. The brain substance is likely to be softened, or even 
reduced to a pulpy consistence on the surface. The fluid in 
such cases will be more dense, and the evidence of inflamma- 
tory action more apparent. Such cases should be properly 
considered as meningitis with effusion, and not as hydro- 
cephalus. 

Symptofns. — The prominent symptom is the large head. 
This is especially true in congenital, or early-acquired cases. 
The head grows steadily, but there is a marked lack of corre- 
sponding bodily growth. The head and abdomen are large, but 
the arms, legs, and chest are thin and small. As the head in- 
creases in size the child is unable to hold it up, and may sup- 
port it with the hands, and later can only rest it on a pillow. 



Hl'DROCEPHALUS. 758 

If the progress of the disease is slower, and the child reaches 
the age when other children learn to walk, it will not make an 
effort, and if placed on its feet will not " brace " itself, but will 
sink helplessly down. If it learns to walk, it will be a slow 
process, and the gait will be unsteady and uncertain. 

The mental development depends upon the effusion. The 
greater the quantity, the less the development. Early in the 
case, the child may seem simply a little backward. There may 
be no development, or very little, or there may be actual loss 
of mentality ; in fact, there may be any condition, from simple 
feeble-mindedness to actual idiocy. In other cases, the mental 
faculties are not much disturbed early, and for a time seem to 
develop normally. It is even possible for marked enlargement 
of the head to take place, without any indication of pressure 
on the brain centers. Dr. Bastian reported a case in which the 
head measured twenty-four inches in circumference at the age 
of two and a half years, with no brain symptoms or other dis- 
turbances. This child's head had been steadily enlarging for 
eighteen months. Such cases are extremely rare, for nervous 
symptoms are seldom absent, even early in the case, and in 
many instances they are the first evidences of trouble, often 
presenting themselves long before the enlargement of the head 
is noticed. 

In these cases, the first symptom of central irritation is 
likely to be a convulsion. These attacks may, at first, be infre- 
quent, becoming more and more frequent as the case progresses. 
There may be slight twitchings of the face, rolling of the eyes, 
or pronounced general convulsions. The enlargement of the 
head is, in rare cases, preceded by symptoms of trouble at the 
base of the brain. Dr. Bastian reports the case of a child four 
years old, who fell, striking the back of the head with great 
force. Soon after it presented symptoms of cerebellar irrita- 
tion. In a year or more the head began to enlarge, and hydro- 
cephalus constituted the prominent condition. 

Pain in the head is always a prominent symptom, even young 
infants showing that they suffer, by frequently crying and 
moaning, and placing the hands on various parts of the head. 
The constant rolling of the head on the pillow, often so mark- 
edly present, is no doubt due to this cause. 

The symptoms in acquired hydrocephalus and those in con- 
genital cases are much the same, except in cases that begin 
after the bones of the skull have become more or less firmly 
united. The symptoms then are obscure, for the signs of 
distention are not visible. The child becomes dull and languid; 
tnere is headache, dizziness, disinclination to play, and it is 
easily fatigued. It sits about and rests its head upon the hands, 
D. C— 48 



754 THE DISEASES OF CHILDREN. 

or in other ways supports it. The gait becomes unsteady and 
irregular, and twitchings and a tendency to convulsions are 
frequent. The pupils react slowly, and finally become dilated, 
and epileptiform seizures, followed by vomiting and severe 
headache, are more or less frequent. There may be numbness 
of the hands and feet, paralysis of certain extremities, hemi- 
plegia or complete inability to walk or even stand. Nystagmus 
and strabism.us are often present, and not infrequently loss of 
vision. The senses of hearing and smell may also be impaired, 
but not so frequently or markedly as that of vision. 

The appetite in most cases is good or even voracious. Di- 
gestion may be unimpaired, even in gluttony, and yet, while in 
some instances the child may be fairly well nourished, the great 
majority early show signs of failing nutrition. This becomes 
more marked as the disease progresses. The body grows thin, 
the muscles atrophy, the skin becomes dry, the abdomen grows 
tympanitic, and little resistance can be offered to other diseases 
that may supervene. 

Prognosis. — Most strictly congenital cases of hydrocephalus 
die in a comparatively short time after birth, and many during 
the parturition or very soon after. The great majority do not 
live longer than from six months to two years. Very rarely a 
case may survive as long as three years. 

The duration of the disease is, however, extremely variable. 
While the course in congenital cases is usually very rapid and 
death may result in a few months, some of the children in 
which the disease is acquired later in infancy or in early child- 
hood, may live to reach the age of five, six, or eight years. 
The duration of those cases in which the disease begins after 
the bones of the skull have become united quite firmly, and 
which present the nervous phenomena described above early in 
the case, will depend upon the activity of the disease and the 
rapidity with which the serum is effused. 

Most cases that run a long course are marked by more or 
less distinct periods of remission, when the head ceases to en- 
large and general nutrition improves. These periods vary in 
duration, sometimes continuing long enough to encourage the 
the belief that the disease has been arrested. Disappointment, 
however, is almost sure to follow. Even if the disease is ar- 
rested and the sutures ossify and the fontanels are filled in, 
there remains the abnormally large head and a more or less 
impaired intelligence. 

Dr. L. W. Sedgwick reported a most interesting case in which 
the termination of a decidedly hydrocephalic condition occurred 
by spontaneous evacuation through the nose. The little pa- 
tient was two years old. Two of his brothers had died of hy- 



HTDROCEPHALUS. 755 

drocephalus. He had had a large head since birth. He com- 
plained frequently of headache, became listless, and often 
wanted to lie down. His sleep was restless, and he often 
awoke with a scream. The head began to enlarge, and soon 
the fontanels as well. The symptoms of brain pressure, such 
as dilated pupils, disturbed respiration, insensibility to sur- 
roundings, etc., made their appearance and progressed to such 
a degree as to make the case appear every day more hopeless. 
At this stage a copious watery discharge from the nose made 
its appearance, and gradually all the threatening symptoms dis- 
appeared. After the lapse of a year, they again made their 
appearance, and were again, and this time permanently, relieved 
in the same manner. 

Another similar case of spontaneous evacuation was reported 
by Barron. This child died, and the autopsy disclosed a small 
opening through the ethmoid bone from the cranium to the 
nose. 

When death results directly from hydrocephalus, it is caused 
by the gradually increasing pressure of the accumulating fluid. 
The child becomes comatose, and remains in this condition to 
the end. Death is due to complete arrest of brain function. 

Hydrocephalic children are extremely liable to acute diseases. 
Bronchitis, pneumonia, intestinal disorders, or some of the 
eruptive diseases frequently terminate the lives of these little 
sufferers. 

It is not uncommon to find, associated with congenital hy- 
drocephalus, other malformations, such as spina bifida, cleft 
palate, and hare lip. Spina bifida is probably the most fre- 
quent, due, no doubt, to the increased pressure of the exces- 
sive fluid, preventing normal closure of the canal. Webbed 
fingers and toes, and impervious nostrils have also been noted. 

Treat7nent. — In a disease which results so generally unfavor- 
ably, very little satisfaction is derived from the use of drugs. 
Of all the medicines, which the old school has used to check 
or reduce the amount of the fluid, the iodid of potash alone 
has kept a place with them. This is still given in moderately 
large doses, and in some cases has appeared to be beneficial. 

Eustace Smith still holds that the chlorid of mercury, per- 
sistently given, will, and often has, succeeded in arresting the 
disease. This opinion is not shared by other equally close ob- 
servers. Homeopathically such remedies as apis mel., arsenic 
alb.y calc. carb., calc. phos., cina, ferriim pJios., helleb., sulphur 
and zinc might be expected to be of benefit in this condition ; 
but experience has done little to confirm this expectation so 
far as the ultimate termination of the disease is concerned. 

Compression by elastic bandages or adhesive straps has been 



756 THE DISEASES OF CHILDREN. 

quite generally employed with doubtful benefit. If the elastic 
is employed, it should be applied "■ just tight enough not to have 
the material impress its pattern on the skin." In using the adhesive 
strips great care is necessary not to apply them too tight, and 
they must be removed and reapplied at intervals. Should symp- 
toms of pressure make their appearance, the bandages or strips 
must be removed at once, and may be reapplied. Dr. Dickin- 
son and Dr. J. Lewis Smith have each expressed the belief that 
the rapidity of the effusion may in this way be modified. Punc- 
ture and partial evacuation of the fluid has been frequently 
performed, but the effect has been merely to give temporary 
relief, since the reaccumulation of fluid is sure to follow, and 
usually more rapidly after each puncture. There is, besides, 
some danger of setting up active traumatic meningitis, though J. 
Lewis Smith characterizes the operation as " simple, devoid of 
danger, and easily performed." He makes the puncture at the 
outer angle of the anterior fontanel, and removes only a small 
quantity each time, and keeps constant pressure applied by 
means of adhesive straps. 

The careful attention to the general health of the child is of 
the highest importance in this disease. It should be very care- 
fully fed. The general nutrition must be kept as good as pos- 
sible. Since the disease is so frequently associated with a ra- 
chitic condition, the remedies suggested by this diathesis will 
often be indicated. Any disturbance of the digestive organs 
must be promptly corrected and the general hygiene carefully 
regulated. 



PART XIL 

DISEASES OF THE SKIN. 



CHAPTER I. 

ECZEMA (CRUSTA LACTEA — MOIST TETTER — SALT-RHEUM). 

Definition. — Eczema is an acute or chronic non-contagious 
inflammation of the skin, characterized by an eruption which 
may be erythematous, papular, vesicular or pustular, or else 
a combination of these forms, attended by more or less infiltra- 
tion and itching, terminating either in discharge with the forma- 
tion of crusts, or in desquamation. 

It is most protean in its manifestations, may involve a cir- 
cumscribed area, or more rarely cover extensive surfaces, and 
is often extremely persistent. 

It may begin with a slight erythema of the skin, accompa- 
nied by a sensation of itching and burning, which, as the dis- 
ease advances, becomes almost intolerable; soon an exudation 
is noticed, that rapidly dries into fine scales ; and, after these 
scales desquamate, the skin is left in a thickened and dry con- 
dition. 

Or it may present vesiculation or pustulation as the first 
noticeable symptom, followed by a sense of heat and swelling. 
The vesicles or pustules, as the case may be, according to the 
number of leucocytes which the contained fluid holds, soon 
rupture, and thick yellowish or greenish crusts are formed, sit- 
uated on an inflamed and exuding surface. These crusts con- 
tinue to form for some time, when suddenly the character of the 
eruption may change, the exudation ceases, and no more crusts 
form, and instead of the inflamed and exuding surface, the skin 
will become dry and desquamate in fine dry scales, leaving the 
integument in a fissured and infiltrated condition. 

Or it may make its appearance in the form of papules, which 
may either preserve their special characteristics throughout 
their course, or pass into other lesions. 

Eczema is no respecter of age, sex, race or conditions of life. 
Infants of a tender age are subject to it, and it is often one of 
the first diseases to attack the new-born. It has no particular 

(757) 



758 THE DISEASES OF CHILDREN. 

section of the country to which it confines its ravages, and is 
met with in country as well as in city practice. 

It does not confine its invasions to the poor, who are quar- 
tered in hovels and surrounded by filth and squalor, but often 
finds its way into the palaces of the rich, and many are the pa- 
tients, reared in the lap of luxury, that come under the physi- 
cian's care for relief from its terrible irritation. 

No particular portion of the body can be called its favorite 
seat, for it is met with on the scalp, face, neck, body, extremi- 
ties, folds of the skin, the hands and the feet. 

Eczema, while met with at all ages, is preeminently a disease 
of childhood. 

In a practice covering a period of nearly thirty years in this 
city, it has been our experience that about forty per cent, of 
all skin diseases are eczematous ; and further, that about forty 
per cent, of all cases of eczema occur in children under ten 
years of age. 

A careful study of cases occurring in individuals of varying age 
w^ill reveal the fact that the disease tends to descend from the 
upper portion of the body to the lower, as the person grows 
older ; for the head, and most particularly the scalp, is affected 
in infancy and youth ; in adult life, the genitals, from their 
functional activity, and the trunk are mainly involved ; and as 
old age gradually and silently overtakes the patient, the disease 
creeps down to the lower extremities and to the feet. 

Etiology. — The causes of eczema are external and internal. 
The common external causes are irritations of a mechanical, 
chemical or thermic nature. The principal internal causes are 
irritation of the alimentary canal, deficient functional activity 
of the kidneys, hepatic derangement, and vital depression. In 
most cases it is probable that the chief factor is reflex irritation 
of the nervous centers, producing a dilatation of the capillaries 
in the different regions of the skin affected. Transmitted ten- 
dencies are believed by some to play a not unimportant part in 
its causation. Dentition, also, is a prominent cause, and while 
the process is a physiological one, and in its normal procedure 
should cause no systemic disturbances yet when the teeth are 
delayed, or when from a tough gum they cause pressure on the 
dental nerve terminals, then by reflex irritation they have the 
power of setting up an inflammation of the skin which, in those 
having a weak and delicate integument, will frequently become 
eczematous ; and anything which tends to lower the vitality of 
the system, combined with impaired nutrition and disturbed 
circulation, may give rise to an attack of this disease. It is not 
uncommon to find a reflex neurotic eczema associated with an 
adherent prepuce. 



ECZEMA— ETIOLOGY. 759 

The idea that vaccination causes eczema was widely accepted 
by both physicians and laity at the beginning of this century, 
and doubtless, had some apparent facts to support it. This 
idea is easily explained by the theory of latent disease, and it 
is possible that when the disease follows upon vaccination a close 
examination of the child would probably reveal plenty of evi- 
dence pointing to an eczematous tendency, either from the 
child's history, or symptoms prior to the operation, or from 
the history of the parents, and the vaccination had simply 
aroused this latent disease into activity, but had not caused it. 
Hov/ever, the best plan to pursue, when about to vaccinate, is 
conservatism ; and unless the vaccination is imperative, to 
wait until the eczema is cured, or its presence disproved. 

A common external cause of eczema in the new-born is the 
injudicious treatment it receives during the twenty-four hours 
following its birth. The sudden exposure of the skin to a 
change of nearly thirty degrees of temperature ; the anointing 
of the surface with inferior, and often rancid oil ; the carelessly 
administered initial bath with its chilling water, coarse cloth or 
rough sponge, irritating alkali soap, and rough towel ; the 
coarse, cumbersomie and illy-adjusted napkin and pinning 
blanket ; the large and often misapplied binder, all tend to fret 
the baby, and not infrequently so irritate the integument as to 
induce a congestion or a follicular inflammation which may be 
a starting point for a widespread eczema. 

Often the vernix caseosa at the first washing is imperfectly 
removed from the scalp, and this being allowed to dry and de- 
compose, induces an inflammation which becomes an eczema 
unless checked. Besides this, other causes are at work. Not 
infrequently, through the carelessness of the mother or nurse, 
the napkins are not changed as often as necessary, and the feces 
are thereby left to ooze into the folds of the skin around the 
thighs and anal region, Avhere they dry, and their sharp edges 
cut and irritate the tender skin ; or the urine flows over the 
genitals, scalding and burning them ; and the milk is vomited, 
saturates the clothing around the neck, and unchanged, is left 
for hours. All these causes cannot fail to produce that con- 
dition of skin known as intertrigo, which is but a step removed 
from eczema. 

Then again, it is not improbable that certain micro-organisms 
which float in the air, or are contained in the water used in the 
bath, play a very important part in the development and con- 
tinuance of eczema in individuals having a tendency to it. 

Another etiological factor that demands attention is the 
abuse of the nursery materia medica, which is responsible for 
a large number of cases. Such common and well-known reme- 



760 THE DISEASES OF CHILDREN. 

dies as castor-oil, goose-oil, sage-tea, catnip-tea, whisky, pare- 
goric, soothing syrups, etc., are all given indiscriminately, and 
produce this disease by interfering with digestion and assimila- 
tion, or by irritation of the nervous system and lessening of the 
general tone. 

Varieties. — The varieties of eczema dependent on the primary 
or characteristic lesion are — erythematous, vesicular, pustu- 
lar, papular, exfoliative and fissured. These forms may, in their 
progress, become complicated with or be followed by certain 
secondary lesions. 

The varieties of eczema dependent on the activity or on 
the duration of the process, are the acute, and sub-acute, and 
the chronic. 

The clinical features of eczematous lesions are often modified 
by locality ; especially is this noticeable on the scalp, face, hands, 
feet and genitals. 

The erythematous variety is characterized by small or large, 
bright or dark-red, slightly desquamative patches, accompanied 
by itching or burning. It is most commonly located on the 
face and genitals. 

The vesicular variety is characterized by the appearance of a 
diffuse or punctate erythema, on which minute, closely-aggre- 
gated vesicles appear, accompanied by burning and itching. 
The vesicles soon rupture, either spontaneously or from scratch- 
ing, and leave a raw, reddened surface, which becomes covered 
with a yellowish, gummy crust. It is attended with more or 
less infiltration and swelling, and the exudation stains and stiff- 
ens linen. Its most common seat in children is on the face 
and scalp. 

The pustular variety may originate from the vesicular form, 
or arise directly, and consists in an aggregation of small pus- 
tules — larger than the vesicles — which rupture and form dark, 
greenish crusts. It is most common in strumous children, and 
its favorite seats are the scalp and face. 

The papular variety consists of small, red, aggregated pap- 
ules, accompanied by severe itching. It is frequently associ- 
ated with the vesicular form. It is apt to occur on the arms, 
forearms, thighs and legs, especially the flexor surfaces. 

The exfoliative variety is a variety only from a clinical stand- 
point, and is characterized by a continuous exfoliation of the 
epidermis, generally from a reddened surface, accompanied by 
considerable itching. It is most commonly observed on the 
neck and extremities. 

The fissured variety also is a clinical variety, and presents 
cracks or fissures of varying size and depth, which are often 
very painful. The palms and soles are its favorite seats. 



E CZEMA—S TMP TOM A TOLOGT. 761 

Unna describes three forms of infantile eczema, attacking 
especially the head and face — the tubercular, the nervous, and 
the seborrheic. The tubercular form is observed mostly on 
the face, or in strumous children, in association with conjunc- 
tivitis, rhinitis and otorrhea. The nervous form is due to 
reflex irritation from derangements of the alimentary canal or 
from teething, and appears chiefly on the cheeks, forehead, 
lower part of the arm, posterior surface of the forearm, and 
radial surface of the back of the hands and wrists. The sebor- 
rheic form is apt to be preceded by a seborrhea of the scalp, 
that makes its appearance shortly after birth. The lesion be- 
comes moist, but still retains its fatty character, and invades 
the ears, forehead, eyebrows and cheeks. It is less irritable 
than the nervous form, and displays a disposition to generalize 
on the genitals, back and lower extremities. 

The majority of these several varieties of eczema pass through 
different stages, which, for practical convenience, may be called 
the first, second and third stages. 

Symptomatology. — In acute cases, the first stage is the period 
characterized mainly by hyperemia, with redness and vesicula- 
tion. This period is often, but not always, ushered in with a 
general malaise, loss of appetite and more or less disturbance 
of the circulation ; and these symptoms are followed soon by 
an eruption covering a variable area and accompanied by heat 
and burning. In a few hours, or, at the most, a day or two, 
after the appearance of the eruption, fine, pearly points are seen 
on the inflamed surface, and with more or less itching the vesi- 
cles erupt. The vesicles are closely grouped and are very small. 
They seldom last more than twenty-four hours, rarely over 
forty-eight ; are made up mostly of serum which contains some 
fibrin and a few leucocytes. The most prominent subjective 
symptom now, is the itching, and the disease is entering the 
second stage. 

The characteristics of the second stage are exudation and 
crusting ; and this stage may last an indefinite period. As the 
disease spreads, the advancing border may be marked by new 
papules and vesicles forming ; or by the stratum corneum be- 
coming exfoliated. This pathological phenomenon is one of 
the natural consequences of the exudation following the pri- 
mary congestion, which instead of raising the layers and forming 
vesicles, may ooze through and float the corneal layer off of the 
cells. As the disease advances and the vesicles mature, the 
character of the contained serum changes ; from being clear it 
clouds, and finally pus forms, and the vesicles become pustules, 
which are ruptured either by friction or spontaneously. Char- 
acteristic yellowish-green scabs are formed upon the surface 



762 THE DISEASES OF CHILDREN. 

from the contents of the pustules, which dry into these scabs, 
soon after they are ruptured. These scabs can be removed by 
brisk rubbings with soap and water, leaving the skin in a red- 
dened and inflamed condition ; and on this reddened and in- 
flamed surface numerous fine beads of exudation soon make 
their appearance. 

The third stage is the stage of decline ; and is characterized 
by a gradual lessening and cessation of all the symptoms ; the 
exudation decreases, the effusion becomes less, the crusts grow 
thinner, the surface dries, and instead of the unsightly scabs 
which have hitherto formed, thin, white scales are seen, which, 
if the patch tends to recover, become finer and adhere more 
firmly, and the skin gradually returns to its normal condition 
without a scar. 

This is the typical course of the disease, but it is not an in- 
frequent occurrence for the attack to stop short at any of the 
stages of development, or advance from the first to the third 
stage, skipping the second. Often the eruption may, from first 
to last, be simply erythematous (e. erythematosum). Again, 
from a condition of hyperemia, the disease may suddenly de- 
velop small, red papules and then linger {e. papulostim), or ves- 
icles may be quickly formed from these papules {e. vesiculosunt) ; 
while in another case the inflammation passes directly to the 
pustular form {e. ptisttdosiim). Lastly, the disease may run its 
typical course, or pass over any of the first two stages, and re- 
main stationary for an indefinite length of time in the third stage 
{e. squamosum). 

The course of the chronic case is somewhat varied, for it may 
start as a primary affection, or with acute or sub-acute symp- 
toms, and halt in the second or third stage, particularly the 
third stage. In these cases the invaded surfaces are generally 
limited, but in unusually severe attacks the eruption may in- 
volve the entire skin. These are exceptions and are very 
rare. The chronic variety is more common than the acute ; 
and when an eczema takes on a tendency to repetition, or 
shows definite lines in its action, and secondary changes ac- 
company these, it may be called chronic. These cases gener- 
ally have considerable pruritus, and occasionally suffer an out- 
break, acute in character. 

When this disease occurs on the scalp — the most common 
locality in infants — it passes from the erythematous and vesic- 
ular stages very rapidly to the pustular ; and the exudation 
forms thick, hard, greenish crusts that are situated on an in- 
flamed and fissured surface. In the crusts that are formed the 
hair is thickly matted, being glued together by the thick, puru- 
lent discharge; and in appearance is much like what honey or 



E CZEMA—S TMP TOM A TOL OG2^. 763 

gum-arabic, when poured on the scalp, would be. If this is 
neglected it will run on for years, and very often abscesses 
form from the retained purulent exudation, and glandular en- 
largements are not rare. 

When occurring on the face it is known as crusta lactea. 
Here it is met with in various stages, but it is mostly symmet- 
rical, and runs a straight course. 

The eyelids are prone to be invaded, and when so situated it 
is exceedingly troublesome. The margins of the lids thicken, 
inflame and infiltrate ; and when it is in this condition, its re- 
semblance to inflammation of the Meibomian glands is very 
strong, and is often mistaken for the latter trouble. The hair 
follicles may become involved, and partial or complete loss of 
the eyelashes will result. The most common termination, 
when occurring about the nose, is the formation of scabs. 

The lips and mouth are often affected ; and when the mucous 
openings are invaded, the disease generally runs a chronic 
course and is very exasperating. The lips become edematous 
and fissured, besides being slightly inflamed, moist and scaly. 
When occurring here, it is mostly of the erythematous form. 

A common and exceedingly troublesome location is on and 
about the ears. They are usually considerably enlarged, swol- 
len and inflamed ; and these symptoms are accompanied by a 
constant exudation, which drips down and hardens into firm 
crusts. The vesicles are generally developed early, and very 
rapidly run into the pustular stage. 

On the genitals it often proves intractable, from the constant 
moisture of the parts. There is heat and redness, and quite 
frequently swelling and severe pruritus. Fissures, which are ex- 
ceedingly painful, form around the margin of the opening, 
when the anus is involved. 

The arms, legs, thighs, flexures of the joints, and the gluteal 
folds, are the seats of what often prove to be stubborn cases. 
These parts are generally affected with severer forms than other 
portions of the body, are accompanied by the most intolerable 
itching, and usually pass directly from the erythematous to the 
pustular stage, where they linger. 

On the hands or feet it usually presents a typical course, but 
often becomes fissured. When occurring here it has but little 
exudation, and consequently but little crusting. The most 
common causes of eczema of the hands and feet, are irritants 
acting locally. On the umbilicus, there is considerable edema ; 
and here it may occur in the pustular or severe {e. rubriini) 
form. In young children and those not old enough to control 
the tendency to scratch, the affected portions have '' scratch 
marks " scattered over them in more or less profusion. 



764 THE DISEASES OF CHILDREN. 

Pathology. — Eczema is essentially a catarrhal inflammation 
of the skin, and, when not due to a local irritant, is either a 
central or peripheral trophoneurosis. 

Diag7iosis. — In the typical course, eczema can hardly be mis- 
taken for other skin diseases ; but in the imperfect or irregu- 
larly developed cases the differential diagnosis requires skill and 
study. 

The erythematous stage is often confounded with erythema, 
but the symptoms brought out by the subsequent course of 
the disease will decide the diagnosis. 

Herpes and scabies have a close resemblance to the vesicular 
stage of eczema ; but the herpetic vesicles are larger and appear 
mostly on the face and genitals, while the eczematous vesicles 
are distributed irregularly over the body and are smaller. The 
characteristic of scabies is the nightly aggravation of itching, 
which is absent in eczema ; and the presence of acari, which 
rapidly disappear under anti-parasitical treatment, will dispel 
all doubt as to the disease. 

In the crusting stage it may be confounded with impetigo 
contagiosa and tinea favosa. The eczema crusts are greenish- 
yellow ; the crusts of tinea favosa are sulphur-yellow and cup- 
shaped ; while those of impetigo contagiosa are superficial and 
have the appearance of being " stuck on." 

The squamous form has a strong likeness to pemphigus folia- 
ceous, seborrhea, dermatitis exfoliativa and psoriasis. Seborrhea 
has larger scales than eczema, and they are oily. Pemphigus 
foliaceous starts from bullae, and has thick, parchment-like 
scales. Large scabs, which are thin and easily detached, charac- 
terize dermatitis exfoliativa, and the surface presents a glazed 
and reddened appearance when they are removed ; the scabs of 
psoriasis are white and are not formed from any exudation. 

E. pustulosum, when involving the scalp, is frequently mis- 
taken for the syphilitic eruption; but there is no previous his- 
tory of syphilis, and the foul, sickening odor, so characteristic 
of the specific disease, is absent. 

Prognosis. — In acute cases the prognosis is always good ; but 
in chronic cases, and especially those in which the mucous 
openings are involved, it should be most carefully and dis- 
creetly guarded, as these cases are so long-lasting and difficult 
to treat. 

Treatment. — As before stated, eczema is rapidly and thor- 
oughly cured by a vigorous and proper treatment, faithfully 
and persistently carried out. There are many chronic cases 
that seem to baffle the best skill of the physician, and yet be 
prolonged for years in spite of treatment intelligently applied ; 
and this seeming non-amenability has given rise, among the 



E CZEMA — TREA TMEN T. 76 5 

laity, to the idea that chronic eczema is incurable ; but in direct 
controversion of this lay opinion, it can be said, positively, that 
all cases of eczema, acute or chronic, will yield to the proper 
treatment. What that proper treatment is, must be deter- 
mined by the study of the personal idiosyncrasies of the indi- 
vidual subject, for one case will rapidly improve under simple 
local treatment, another gradually grow worse under the same 
measures, until they are substituted by constitutional remedies, 
when it quickly mends ; while still another will show no im- 
provement under these measures used singly, but when they 
are combined, a rapid change for the better is noticeable. While 
some are so readily amenable to the simplest local treatment, 
and others yield quickly to the constitutional, the majority of 
cases are seemingly not affected by either used singly ; but 
when both of these measures are combined, a rapid and perma- 
nent cure will generally be the result. 

The local treatment may be divided into two classes — sooth- 
ing and stimulating. As to the application of these classes, 
intelligence and a knowledge of the results to be obtained from 
their use, are required ; and one physician, with no more at his 
command than simple olive-oil and ordinary housekeeper's soft- 
soap, can accomplish more, where these agents are intelligently 
used, than can another, with a formidable array of drugs used 
without a knowledge of their application ; and the great car- 
dinal principle in the use of these measures is, to soothe acutely 
inflamed surfaces, and stimulate the chronic, dry, scaly skin. 
The degree of irritation should always be governed by the re- 
quirements of the individual, for no two cases present exactly 
similar appearances, and no set rule can be laid down for them. 

In using soothing applications, the crusts must be removed, 
so that the preparations to be used, can come in actual contact 
with the diseased skin itself. In many cases, the crusts are 
very difficult to remove, and sometimes great skill and patience 
are required in their thorough removal, without causing the 
patient too much discomfort. Generally, however, the appli- 
cation of warm, soft water, combined with gentle friction, will 
be sufficient to thoroughly cleanse them from the skin ; but 
frequently some crusts are too hard to be removed in this man- 
ner, and the application of warm olive-oil will soften them suffi- 
ciently to be washed off with the water ; while others are so 
difficult as to require the use of sapo viridis (green soap), which 
effectually removes the hardest crusts, and in addition, the 
masses of dead, epithelial cells, exudation, and other debris, 
leaving the inflamed skin in a thoroughly clean condition, ready 
for the soothing effects of the emollient application, and the 
healing process. It often occurs, especially on the scalp, that 



766 THE DISEASES OF CHILDREN. 

the crusts are interlaced with hairs, and their removal can be 
accomplished rapidly and painlessly in the following manner; 
raise one corner of the crust, and with a pair of sharp, fine- 
pointed, curved scissors, snip the hairs, gradually raising the 
crust and cutting the hairs until it is entirely freed ; then wash 
the surface of all remaining extraneous matter. 

After the surface has been thoroughly cleansed, and all crusts 
and scabs softened and removed, the skin should be immedi- 
ately anointed with some soothing preparation, so as to pro- 
tect the raw surface from all atmospheric irritation. It matters 
not what this emollient be, just so long as it fulfills the required 
conditions. Olive-oil, either cold or warm, is the most common 
in use, and is also the most simple. Various ointments and 
oleates have been used, some with highly gratifying success, 
and others with indifferent results. Some patients cannot bear 
what is apparently borne with benefit by others, and these 
emollients should be used according to the various individual 
requirements. In some cases with slight inflammation, and in 
which the exudation is the principal symptom, equal parts of 
starch and oxide of zinc, or buckwheat or rye flour dusted 
over the affected surfaces frequently, proves very beneficial. 
To allay the intense itching, cloths wrung out in hot water 
and applied over the parts, or the application of a mixture of 
one dram of carbolic acid and an ounce of glycerine to a pint 
of hot water, has a decided anti-pruritic action. During the 
first and second stages, peroxide of hydrogen, diluted with one 
or two parts of water, may be applied with almost magical ef- 
fect. In cases in which large areas are involved, great care 
should be used in the application of mercurial and other oint- 
ments over too large an absorbing surface, as severe constitu- 
tional symptoms may arise, much to the annoyance of both 
the patient and physician. 

When a chronic case presents a dry, scaly, indurated and 
thickened skin, the stimulating treatment is indicated. Such 
severe irritants as green soap, soft and various other potash 
soaps, etc., are best for this purpose, and frictions with these 
set up a sub-acute inflammation, when the irritants can be dis- 
continued, and emollient applications used. After the use of 
the irritants the following will prove useful in many instances : 
Boil one dram of gelatin, two of glycerin, and three of water 
until the gelatin is thoroughly dissolved, and then add one 
dram of oxide of zinc. When required for use this should be 
heated and quickly applied with a stiff brush, as it rapidly hard- 
ens into a thin, transparent, flexible scale. An ointment com- 
posed of one dram of white oil of birch to the ounce of vaselin, 
has proved beneficial in stubborn cases. 



ECZEMA— TREATMENT. 767 

The constitutional treatment can also be divided into two 
classes, viz., hygienic and therapeutic ; and the hygienic farther 
into considering separately the diet, habits, clothing and clean- 
liness, and surroundings. 

In the feeding of an infant, regularity of diet is as essential to 
its well-being as to an adult ; and the practice of nurses and moth- 
ers putting the child to the breast every time it cries, is to be 
strongly deprecated ; for if the little one cries very much it is 
undoubtedly sick, and if it be troubled with indigestion, the 
breast every ten minutes, or fifteen, or even every half-hour only 
aggravates the existing trouble : and as indigestion is the cause 
of many cases of infantile eczema, it is plainly evident how 
great should be the care concerning the regularity of the diet, 
as irregular feeding is the main cause of indigestion in infants. 
In many cases the fault lies, not with the irregularity of the 
feeding, but with the food on which the child is fed, for sometimes 
the indigestion is merely a nervous demonstration of hunger, due 
to the deficient quality or insufficient quantity of the food, which 
sets up a condition of malnutrition. Or it may be that improper 
food, such as pastry, pickles, insufficiently cooked, starchy mat- 
ters, tea, coffee, meat, etc., are given to the child, producing 
indigestion. Frequently anger, fright, joy, or some other in- 
tense mental excitation, or even errors of diet in the mother or 
nurse, by deteriorating the milk, produce a deranged digestion 
in the infant. 

Sometimes the physician is called to see some puny, ill- 
nourished infant, whose face and scalp are almost one solid 
mass of eczema. What are the surroundings of such a case? 
Rags, dirt, and filth ; and an existence in a filthy, illy-ventilated 
room, entirely innocent of sunshine. The poor, hard-worked 
mother has not sufficient vitality to furnish the necessary qual- 
ity of the milk for the demands of the child, and her purse is 
too slender to procure the required artificial food. And the 
cleanliness of the child is also neglected, for the mother cannot 
spare the time to devote to the necessary washings and changes 
of clothing ; and thus, in illy-ventilated and poorly-lighted sur- 
roundings, the poor little sufferer, reeking in its own excretions, 
lives on day after day, through a tortured and miserable 
existence. 

From the above it is plainly evident how absolutely necessary 
to the health of the average infant is regular feeding, proper 
food, cleanliness, and good hygienic surroundings. If the food 
is irregularly furnished, fix certain hours for the feeding and see 
that they are observed. When the child is nursing, and the 
milk does not furnish sufficient nourishment, the mother's or 
nurse's diet should be looked after, and their general health im- 



768 THE DISEASES OF CHILDREN 

proved. If she does not secrete the necessary quantity of 
milk, some good artificial food should be given the baby in 
addition to the breast ; or if the child be old enough, and the 
season be fall or winter, it should be weaned, and that artificial 
food which best answers all needs of its system, given. If 
bottle-fed and insufficiently nourished, the food should be 
changed and experimented with until someone is found that will 
suffice. If the bowels are constipated or in adiarrheic condition, 
or the kidneys not properly performing their work, they should be 
promptly looked after, and measures adopted that, in each in- 
dividual case, will best restore them to their normal status. 
Where improper food is the cause, all indigestible foods, as 
pastry, pickles, tea, coffee, and the various nitrogenous sub- 
stances are to be prohibited; and only such farinaceous foods 
fed as will meet all the requirements of that particular infant. 
Often the mother or nurse, after undergoing some strong men- 
tal or nervous excitement, consoles herself by putting the baby 
to the breast ; but this should not be done, and instead, the 
breast-pump should be used, and the breasts thoroughly emp- 
tied of their poisoned contents, and the infant not allowed to 
nurse for two or three, or even four, hours. This is to be 
strongly insisted upon, for any woman who gives her child the 
breast after severe anger, fright, excessive joy or grief, or any 
other intense mental excitement, runs the risk of causing it to 
have indigestion, or seeing it thrown into convulsions, often 
followed by speedy death. 

Nor should the bathing be neglected ; and the napkins are to 
be changed as soon as soiled, and the parts washed before clean 
ones are replaced. By this it must not be inferred that we ad- 
vocate the frequent bathing of the infected areas, but, rather, 
bathing for reasons of bodily cleanliness. Instead of using 
harsh, stiff, linen clothing to scratch and irritate the tender skin, 
soft flannels should be the material employed in the make-up 
of the wardrobe. The various infant powders are to be ban- 
ished, as they absorb the moisture of the skin, sour and cake, 
and the rough edges cut the delicate cuticle ; and instead of 
these preparations, a thin slip of absorbent cotton should be 
placed between the folds of the flesh and frequently renewed ; 
and this of itself will in some cases cure an intractable eczema. 

When the physician begins to treat an eczema he should in- 
sist upon his instructions being carried out to the letter, even to 
his becoming dogmatic ; for it is invariably the rule that the 
nurse or mother will only half obey his orders, and failure fol- 
lows, which will be damaging to his reputation. 

In considering the indications for the remedies, they will be 
found to be both numerous and varied. A large percentage of 



ECZEMA— REMEDIES. 769 

all the remedies in the materia medica have directly or indi- 
rectly some decided action or effect on the skin, and, hence, in 
a work like this, it is impossible to consider all, so we will men- 
tion but a few of the leading ones. 

Ammonium carb. — Eruption dark red and bleeds easily; in- 
tense pruritis relieved by scratching, but followed by sensation 
of burning ; nates, genitals and anus excoriated and painful ; 
especially useful in eczema of flexures of joints. 

Arsenicum alb. — Eruption burning and itching, painful after 
scratching ; crusts are surrounded by an inflamed, painful border ; 
pain and pruritis, worse at night and from cold and scratching, 
but better from warmth ; hair falls out ; intense thirst ; useful 
in chronic cases that present a dry, white, parchment-like skin, 
covered with fine branny scales. 

Calcarea carb. — Eruption covered with thick, greenish-yellow 
crusts, formed from the gummy, yellowish, purulent secretion ; 
intense burning pruritis, worse at night and after nursing, bet- 
ter from warmth ; painful fissures and cracks of the skin ; scalp 
most commonly involved ; useful in light-complexioned, plump 
children of a strumous diathesis. 

Croton tig. — Variable appetite ; sensation of water in abdo- 
men ; stools diarrheic, thin, watery, green mucus, exceedingly 
offensive and forcibly shot out of rectum ; urine high colored 
and fetid ; face covered with eruption of vesicles, worse in 
afternoon ; intense pruritis aggravated by warmth of bed at 
night, better in morning and from cold ; eruption on the face 
and genitals. 

Graphites. — Skin dry and with a tendency to fissure, the 
exudation from which excoriates the surrounding parts ; the 
eruption is moist, with thick crusts situated on raw, inflamed 
surfaces, which exude a thick, corrosive, sticky serum ; intense 
pruritis, aggravated from scratching, and at night ; eruption on 
the palms of the hands and behind the ears. 

Lappa major. — Eczema of the scalp extending to the face ; 
moist, bad-smelling eruption on the heads of children ; swelling 
and suppuration of the axillary glands ; disposition to boils. 

Mercurius. — Skin dirty yellow ; eruption involves large areas, 
which itch intolerably, especially when warm ; exudation of a 
thin serum, which forms dry scales, or an acrid discharge burn- 
ing and excoriating the skin, and drj^ng into yellow crusts ; itch- 
ing and bleeding after scratching ; tendency to lymphadenitis ; 
profuse perspiration. 

Mercurius pre cip. ruber, — Pustular eczema about anus, geni- 
tals or umbilicus; pustules on inflamed base and very painful to 
touch ; crusts are formed from the yellowish pustular exudation, 
they crack and from these fissures the pus is constantly oozing. 
D. C— 49 



770 THE DISEASES OF CHILDREN' 

Oleander. — Oozing behind the ears, and on the back of the 
head ; smooth, shining surface, covered with drops of serum ; 
extreme sensitiveness of the skin ; even the friction of the 
clothing causes soreness and rawness. 

Rhus tox. — Eruption on a raw, excoriated surface, exuding a 
thin, sticky, offensive serum, which forms thick crusts ; mostly 
on face and scalp ; burning and itching, worse at night. 

Stannum. — In eczemas due to the presence of intestinal 
worms ; child is very irritable and excessively hungry, while 
every meal is followed by nausea and vomiting ; eczema of 
lower extremities. 

Sulphur. — In the vesicular and pustular varieties, with burn- 
ing pruritis, worse at night, and leaving a sense of soreness 
after scratching ; exudation, a fetid pus forming thick crusts 
which bleed easily. 

Viola Tricolor. — Humid eruption, with intolerable, nightly 
itching ; discharge of yellow water or pus ; swelling of the cer- 
vical glands; eczema on the face. 

Zinc phos. — Especially useful in eczemas of head and scalp, 
due to deranged nervous system ; trembling and jerking of the 
muscles ; fidgety, restless, and with a crawling or creeping sen- 
sation over body ; pruritis worse during afternoon and evening. 



CHAPTER II. 

PSORIASIS (psora — DRY OR SCALY TETTER). 

Definition. — Psoriasis is a constitutional, non-contagious 
disease of the skin, characterized by dry, reddish, sHghtly ele- 
vated patches, covered thickly with whitish or grayish, mother- 
of-pearl like, imbricated scales. It may occur on any part of 
the body, but is especially liable to appear on the tips of the 
elbows, fronts of the knees, just below the patella, on the hips 
and on the head. The elbows and knees are oftener affected 
in females than in males. When the head is attacked, the erup- 
tion extends beyond the margin of the hair, and often forms a 
ring around the forehead and ears. The back is more commonly 
involved than the chest. The nails are at times affected, and 
the free margins may become whitish, thickened and friable. 
The palms and soles rarely suffer. A sensation of itching is 
sometimes present in a marked degree, but as a rule it is not 
troublesome. 

Etiology. — Psoriasis seldom appears during infancy, but may 
occur at any age after three years. Heredity seems occasionally to 
play a part in its causation. It prevails more in winter than in sum- 
mer, and in many cases disappears entirely at the latter season, 
to return with the advent of cold weather. While a few cases 
may appear to depend upon a gouty or rheumatic diathesis, it is 
a singular fact that a great majority of psoriatic patients often 
appear to be the picture of health. In predisposed subjects 
debiHtating influences may precipitate an attack. 

Symptomatology . — The lesions invariably begin as small, red 
papules, scarcely raised above the level of the skin, which 
quickly become covered with whitish, imbricated scales. The 
scaly papules usually increase at their periphery, and form 
flattened patches varying from the size of a pea to two or more 
inches in diameter. In the progress of the disease the patches 
tend to run together as they increase in size, and their circular 
outline becomes lost. Occasionally the centers of the patches 
clear up and rings or festoons are formed. As the discs increase 
in size, the skin becomes more infiltrated, and the scales become 
large, imbricated, and more or less adherent. When scales are 
removed numerous bright red dots — apices of hyperemic pa- 
pillae — are revealed, which are easily made to bleed. 

(771) 



772 THE DISEASES OF CHILDREN. 

Various designations were given by earlier dermatologists to 
the different clinical appearances presented by psoriasis in dif- 
ferent cases, such 2,'i> p. punctata, when the lesions are pin-head 
size ; /. guttata, when the discs are small and round, and have 
the appearance of drops of mortar scattered on the skin ; /. 
nummularis, when the discs have the size of small coins ; /. 
'diffusa, when the patches become irregular in size and cover a 
•considerable amount of surface ; /. amiularis, when rings have 
been formed by the patches clearing away in the center, while 
extending upon their periphery ; and /. gyrata, when these 
rings join each other, and form by their coalescence broken 
semicircles, or graceful festoons. These descriptive names must 
not be regarded as indicative of so many different varieties of 
the disease, but simply as expressive of the varying forms the 
eruption may assume during its progress. 

PatJiology. — Concerning the pathology, the process is sup- 
posed to begin as a hyperplasia of the epithelial cells, and the 
inflammatory changes in the corium are believed to be second- 
ary to it. The peculiar whiteness of the scales is due to the 
presence of air between the dry, epithelial cells. 

Diagnosis.— Th.Q diagnosis of psoriasis in well-marked and 
typical cases is generally unattended with difficulty. Atypic 
cases are, however, sometimes encountered where the lesions 
bear a close resemblance to those of eczema, syphilis, lupus 
erythematosus and dermatitis exfoliativa. In eczema there is 
apt to be a history of moisture, while in psoriasis the lesions are 
invariably dry and scaly. The scales of psoriasis are more 
abundant, larger and whiter than those of eczema. The patches 
of the former are bold and well defined, while those of the lat- 
ter shade off into the healthy skin. Itching is, as a rule, more 
pronounced in eczema than in psoriasis. A squamous syphilide 
may be mistaken for psoriasis. In the latter the patches ap- 
pear to be on the surface, are very scaly, and have a bright-red, 
inflammatory tint ; while in the former, they are dull-red or 
ham-colored, deeply indurated and only scantily covered with 
scales. Psoriasis may show repeated outbreaks of the same 
kind of eruption, while in squamous syphilide previous eruptions 
will have been of a different type. A scaly eruption confined 
to the palms and soles is almost without exception a syphilide. 
Lupus erythematosus is usually found upon the cheeks, the 
scales are scanty and of a yellow or gray color, and are firmly 
attached to the openings of the sebaceous glands. In derma- 
titis exfoliativa the suddenness of the attack, the universality 
of the cutaneous inflammation, and the abundant and continu- 
ous exfoliation of dry, thin, papery scales are sufificiently pa- 
thognomonic. 



PSORIASIS. 773 

Prognosis. — Psoriasis is one of the most rebellious of the 
inflammatory diseases of the skin. The prognosis is good as far 
as any one individual attack is concerned, in ordinary cases. 
The disease, however, is prone to relapse after a longer or 
shorter period. Left to itself it may run a variable course, con- 
tinuing for months, and often for years, or occasionally disap- 
pearing spontaneously. 

Treatment. — The constitutional treatment of psoriasis is of 
the greatest importance. The following are the oftenest indi- 
cated remedies : 

Arse?ticum iod. — Persistent itching and burning, and marked 
infiltration ; the skin is dry and scaly, and pricking sensations 
are experienced ; useful in scrofulous subjects. 

Arsenicum sulph. — Irregularly rounded, reddish spots, cov- 
ered thickly with scales, occurring on the trunk, knees, elbows, 
and hips, attended with itching and burning; adapted to ca- 
chectic subjects. 

Borax veneta. — Psoriasis on the face and scalp, especially 
when the skin displays a dingy, unhealthy look. 

CJirysarobinum. — In acute cases attended with itching, and 
when the eruption is profuse on the lower extremities. 

Cinnabaris. — In scrofulous and syphilitic subjects, or when 
the patches are irritable and of a fiery red color. 

Manganum. — In inveterate cases and in rheumatic and gouty 
subjects. 

Mercurius sol. — In light-haired people, and in syphilitic and 
scrofulous individuals ; the scalp is frequently painful to the 
touch, and dry, scaly spots appear all over the body. 

Natrum ars. — The skin is dry and rough, and the patches are 
slightly reddened and covered with thin, whitish scales ; patient 
is sensitive to cold and becomes easily fatigued. 

Nitric acid. — Dry, scaly skin, with stinging sensation in the 
patches, in dark-haired people. 

Petroleum. — Psoriasis of the hands and scalp ; painful sensi- 
tiveness of the skin, itching worse in the open air. 

Silicia. — The nails are brittle, thickened and yellow. 

Sulphur. — Of service to begin treatment with ; in obstinate 
cases to eradicate a tendency to return. 

Local measures are of more or less benefit, according to the 
nature of the case. The scales may be removed by the free 
use of soap lotions, alkaline baths, or a two-per-cent. solution 
of salicylic acid in a mixture of alcohol and castor-oil. Marked 
success follows the use of a ten-per-cent. solution of chrysaro- 
bin in liquor guttapercha, thinly painted on the affected patches 
by means of a stiff paint brush, and renewed every two or three 
days. On delicate skins it will sometimes produce an acute 



774 THE DISEASES OF CHILDREN. 

dermatitis, and should always be used with caution. It has the 
disadvantage of staining the skin temporarily. Owing to the 
uncertainty of obtaining a good quality of chrysarobin, some 
dermatologists prefer a five-per-cent. solution of gun powder, 
of which the former is the active principle. On the edge of 
the scalp and about the face a five-per-cent. ointment of beta- 
naphthol or of thymol is preferable to chrysarobin. 

A radical change in the dietary is frequently productive of 
the most beneficial results. As a rule, all stimulating fluids 
and seasoned articles of diet should be avoided. Some cases 
are markedly benefited by entire abstinence from nitrogenous 
foods, while others steadily improve on an exclusive beefsteak 
and hot-water diet. 



CHAPTER III. 

MILIARIA RUBRA— (red GUM, STROPHULUS, TOOTH-RASH). 

Definition. — Milaria rubra is the strophulus or red gum of 
older writers, and is very common among infants, particularly 
during the period of dentition. It is characterized by an erup- 
tion of small red or white papules, varying in size from a pin's 
head to a small pea. These papules are due to a congestion 
of the orifices of the sweat ducts, and appear in successive 
crops, each crop remaining from ten to fourteen days, when 
it disappears and a new crop takes its place. The papules are 
in patches of a dozen or more, and are surrounded by an erythe- 
matous border. 

Etiology. — The principal factor in the causation of miliaria 
rubra in children, is dentition. This process, when accompanied 
by abnormal conditions, is highly productive of it, and many 
cases end spontaneously with the cessation of the dental irrita- 
tion. When occurring in extreme infancy, it is a result of a 
congestion of the sweat-glands, due to over-dressing, warm 
weather, and the rooms in which the child is kept being over- 
heated. Flea-bites are often an exciting cause, when from lack 
of cleanliness, these little pests are allowed to be generated. 

Symptomatology . — The principal seats of the eruption are on 
the face, neck and arms ; although it may be distributed over 
nearly the entire body. The eruption is made up mostly of 
papules, which are raised somewhat above the surface, their 
margins are sharply outlined, are rounded, pale and to the 
touch have a peculiar hard or '' shotty " feeling. In the center 
of these papules is a semi-transparent spot, giving the papules 
the appearance of a vesicle, but on being punctured no fluid 
escapes. 

The papules usually appear over considerable extent of sur- 
face, generally on the face and arms, and are accompanied by 
considerable itching ; and as they are scratched, as a result of 
the itching, numerous fine points of blood are exuded, which 
dry into minute scabs, on their apices. The eruption usually 
reaches its maximum in three or five days ; and then, unless 
prolonged by some condition, gradually disappears. In infants 
of a scrofulous diathesis, the papules rapidly undergo suppura- 
tion and form pustules. 

(775) 



776 THE DISEASES OF CHILDREN. 

Diagnosis. — Erythema papulosum is the only disease that 
can be confounded with miliaria rubra ; and the two can be 
readily differentiated by the severe constitutional disturbances 
of eczema, and the exceedingly mild, and lack of constitutional 
symptoms of miliaria rubra. 

Prognosis. — Miliaria rubra is a mild disease, and of itself is 
never fatal. If severe symptoms are present, they are due to 
some complication. 

Treatment. — About the only treatment required is hygienic, 
as internal medication is seldom, if ever, indicated. The diet 
is to be carefully attended to, and the bowels regulated. If 
the gums are swollen and tender, causing much discomfort, 
they should be freely incised. Strict attention should be paid 
to the cleanliness of the child and all unnecessary articles of 
clothing should be forbidden to be put on. 

Antimonium crudum, apis mel., borax, calc. carb., chamomillay 
etc., may be given as indicated, but in the majority of cases, no 
remedies are required. 



CHAPTER IV. 

ERYTHEMA (ROSE RASH.) 

Definition. — Erythema is an inflammatory condition of the 
skin, characterized by an eruption of tubercles, macula or 
papules, accompanied by a varied degree of pruritis and burn- 
ing. 

It is acute, non-contagious and non-specific in character, and 
usually runs its course in a few hours, or at most four or five 
days. Its principal symptom is an hyperemia which appears 
very suddenly on the surface, and is irregular in outline and 
of variable extent. The eruption on first appearing is of a 
bright-red color, which gradually changes to a bluish tint. At 
first there is usually neither swelling nor hypersensibility ; but 
with the progress of the symptoms the bluish deepens to a dark 
rose-red, the skin becomes extremely sensitive, indurated and 
oftentimes fissured, while in neglected cases it may become 
ulcerated. 

While erythema means a redness or hyperemia, the defini- 
tion of the term is, more strictly speaking, a symptom ; and it 
often occurs in the course of diseases, especially of the exanthe- 
mata. Properly treated in its incipency, erythema is usually 
very simple. 

Etiology. — When occurring on the skin of a new-born infant, 
it is usually a mild cutaneous congestion, due to the change 
from the influence of the womb during fetal life to the atmos- 
pheric irritation immediately after birth, and requires no treat- 
ment as long as it remains a simple hyperemia. 

The causes of this affection may be divided into two classes, 
viz.: idiopathic and symptomatic. The idiopathic are, extremes 
of heat and cold ; rapid and excessive changes in the weather ; 
hot weather ; too frequent bathing ; frictions from towels and 
strong soaps ; insufficient bathing ; fecal and urinary matters on 
soiled napkins ; pressure from stiff and tight clothing and shoes, 
instruments, such as trusses, braces, etc.; burns and scalds. The 
symptomatic cases generally occur as a symptom of some inter- 
nal disease, as scarlet fever, measles, etc. 

Varieties. — Early writers divided this affection into classes, 
according to the extent of surface involved and the shape 

(777) 



778 THE DISEASES OF CHILDREN. 

assumed by the eruption ; but this classification is entirely use- 
less, as these manifestations are but the various stages of the 
disease and not separate or distinct varieties. There are, how- 
ever, different varieties according to the character of the erup- 
tion ; and we shall confine ourselves to the three forms con- 
cerned in childhood, and they are : erythema simplex, erythema 
intertrigo and erythema nodosum. 

Symptomatology — Erythema simplex. — The simple form of 
erythema usually occurs during the course of the acute internal 
inflammatory diseases ; mostly, however, during the course of 
those depending on the period of dentition. It often occurs 
during a high fever from any cause, and especially in those 
children having an active cutaneous circulation. The first 
symptom is the appearance of slightly reddened patches, more 
or less numerous, and of different shape and extent, accom- 
panied by a greater or less degree of pruritis. The color dis- 
appears on pressure, but rapidly returns on the removal of the 
pressure. There is no swelling, infiltration or fissuring of the 
skin, and as the rash becomes older, its color deepens. After 
the disease has run its course, the cutaneous symptoms disap- 
pear, and the eruption usually ends in desquamation. 

Erythema mtertrigo. — This form usually attacks the folds of 
the skin about the nates, hips, anus, arms, neck, flexures of the 
joints, inner aspect of the thighs, and the genitals. Here it 
begins as a simple redness, and when neglected, generally runs 
into a true eczema. In severe cases, there is ulceration, the 
surface presenting a raw, deep-red, and angry appearance ; from 
which a serous or sero-purulent exudation, very fetid and acrid, 
is discharged, accompanied by severe pruritis, burning and pain. 
When the ulceration has ceased, red or copper-colored spots 
mark the site of the ulcers, and are very slow in disappearing. 
If slight, this form will last but a few days, while aggravated 
cases may be prolonged for months. 

Erythema nodosum. — Is the variety that generally occurs 
singly, but is sometimes accompanied by one of the other 
forms. It shows a preference for the anterior portion or ex- 
tensor aspect of the arms and legs, although it may be found 
on other portions of the body. Its chief characteristic is an 
eruption of small, painful spots or nodositers, which gradually 
increase in size. They vary in size from a pinhead to a split 
pea and never suppurate. After they begin to swell, the skin 
becomes tender to touch, stretched, and finally so tense as to 
interfere with the movements of the member, and causes great 
pain. In a few days the swelling diminishes, the tension less- 
ens, and the pain subsides until it finally ceases altogether. 
The eruption of the nodules is ushered in with a variable 



ERYTHEMA {ROSE RASH). 779 

degree of fever and general malaise. It usually develops rapidly 
and runs an acute course. 

Diagnosis. — Simple erythema is very close in its resemblance 
to scarlet fever and erysipelas. From scarlet fever it can be 
differentiated by its accompanying some other disease, its 
limited area, short course, light color, absence of throat 
symptoms, and only the superficial cutaneous strata being 
involved. 

From erysipelas, the diagnosis is somewhat harder, and 
requires more skill. Erysipelas has swelling, smarting and 
burning; it involves the deeper layers; its margins are well de- 
fined and slightly elevated ; and it progresses slowly to new 
areas ; while erythema suddenly appears on one spot, and in a 
few hours, or days, as suddenly disappears ; there is no swelling 
or smarting, some pruritis and burning; it involves only the 
superficial layers, and its margins gradually merge off into the 
normal color. 

Erythema intertrigo is, in most cases, easily recognized, but 
may sometimes be mistaken for eczema, as there are so few 
diagnostic points to differentiate by ; and while the intertrigo 
may become an eczema, the chief point of difference is the in- 
filtration of the skin, which is entirely lacking in the erythema, 
and when present is indicative of eczema. 

Erythema nodosum, when occurring on the anterior aspect of 
the leg, is at first glance mistaken for a series of bruise marks, but 
the absence of any history of violence decides against trauma- 
tism. It has many features in common with syphilitic gum- 
mata, but its more acute course will differentiate. Boils and 
abscesses are smaller, lighter colored and suppurate ; while 
erythema nodules are larger, darker colored and never suppu- 
rate under any circumstances, but disappear by absorption. 

Prognosis. — In the majority of cases, the prognosis is good, 
as the disease tends to a spontaneous termination ; but when it 
occurs in children suffering from intestinal troubles, as entero- 
colitis, colitis, thrush, etc., the prognosis should be guarded, as 
these cases are liable to end fatally, especially when involving 
an intertrigo. 

Treatment. — Simple erythema requires no treatment for it- 
self, but the whole attention of the physician should be directed 
to the disorder which occasioned it. Usually, in the intertrigo, 
strict cleanliness, regulation of the bowels, separating the over- 
lapping folds and keeping them separated, the application of 
some powder, as lycopodium, equal parts of starch and oxide 
of zinc, etc., or zinc ointment, and the internal administration 
of the indicated remedy will be followed by prompt improve- 
ment. In erythema nodosum, the best treatment is rest in bed, 



780 THE DISEASES OF CHILDREN. 

hot applications and compresses of hamamelis, a good gener- 
ous diet, regulation of the bowels and the indicated remedy. 

The remedies are indicated as follows : 

Aconite. — Fever; thirst; restlessness; skin red, hot, swollen, 
shining and painful ; worse at night. 

Arsenicum. — Intense thirst ; great pain ; burning and itching 
of the skin, worse after scratching; ulcers dark and angry; 
exudation very fetid and excoriating. 

Belladonna. — Face flushed ; head hot ; skin exquisitely pain- 
ful to touch ; inflamed red patches, breaking out irregularly 
over the body, but mostly on face and neck ; smooth, scarlet 
redness of the skin. 

Chelidonium. — Prostration ; sleepiness ; large, red, round 
patches on arms and face ; burning pain and pruritis ; spots dis- 
appear in a few hours. 

Lactic acid. — Debility ; aversion to motion, wants to lie still ; 
bright-red spots or patches on different parts of the body, es- 
pecially anterior portion of thighs and legs. 

Nux vomica. — Alternate diarrhea and constipation ; general 
debility, with trembling of the limbs ; eruption dark, painful 
and intensely pruritic. 

Rhus ven. — Red spots from half an inch to two inches in di- 
ameter, especially on the legs below the knees, painful and 
changing color into bluish, then greenish-yellow. 

Ustilago. — Eruption very fine and of a deep-red color ; spots or 
nodules about the size of a pinhead, very painful and aggra- 
vated by scratching ; eruption assumes an annular form when it 
occurs on face or neck. 



CHAPTER V. 

ZOSTER (herpes ZOSTER, ZONA, SHINGLES). 

Definition. — Zoster is an acute, non-contagious, non-specific 
inflammation of the skin, characterized by an eruption of vesicles 
which follow the course of some cutaneous nerve or nerves, 
and accompanied by an acute neuralgic pain. These vesicles 
appear in groups, which vary in size and shape, on an inflamed 
surface, while between the groups, the skin is healthy in color, 
appearance and function. 

It is a self-limited disease, and usually runs its course in from 
ten to twenty days ; and is accompanied by few, if any, severe 
constitutional symptoms. It has no particular part to which 
it is confined, but may occur on any portion of the skin. It is 
met with most frequently involving the intercostal nerves, and 
when it occurs here it is known, in popular parlance, as shingles. 

There is a widespread opinion among the laity that shingles 
would speedily prove fatal, if, when occurring on both sides, it 
should meet and form a complete circle around the body ; but 
the fallacy of this is at once apparent, for zoster involves the 
course of the nerves, and as the nerves do not encircle the body, 
the two approaching borders can never coalesce. 

Zoster occurs with equal frequency in both sexes, and is 
oftenest observed in individuals under twenty and over forty 
years of age. It is rare in infants, and is most frequently seen 
in children between the ages of five and thirteen. 

Etiology. — The unvarying rule of the eruption of zoster follow- 
ing the course of a nerve, would suggest some connection with 
the nerve so followed ; and it is in most cases dependent upon 
some inflammatory condition of that nerve. Thus it will be 
seen that it is of nervous origin. A careful study of those who 
are affected with it would reveal the fact that the majority have 
a thin and delicate skin. 

The exciting causes are all those causes, which, acting upon 
the cutaneous nerves, produce a neuritis of them, and they are : 
pressure, burns, wounds, cuts, bruises, or traumatism of any 
kind ; and this inflammation or neuritis, in connection with the 
requisite predisposition, will, in most cases, be followed by an 
eruption of zoster. 

(781) 



782 THE DISEASES OF CHILDREN. 

Symptomatology. — Zoster resembles the eruptive fevers, in- 
that it is preceded by a prodromal period, and the length of 
this period is unknown. The prodromal symptoms are: more 
or less itching along the track of the inflamed nerve, neuralgic 
pain of greater or less intensity, fever, restlessness, loss of ap- 
petite and intestinal irritation. Three or four days after these 
symptoms are noticed, the eruption makes its appearance in the 
form of fine vesicles situated on patches of inflamed skin. 
These inflamed patches vary in size and shape ; they may be 
about the size of a silver half-dollar or as large as a small saucer, 
while between these inflamed areas the skin remains normal. 

In children, in the so-called infantile zoster, there is seldom 
any neuralgia, and the only disturbance which may be noted is 
the zosterian fever, with some gastric distress. 

The vesicles, at first, are fine and transparent, being filled 
with a clear, colorless serum ; but in a few days they increase 
in size, lose their transparency, and become yellow and turbid. 
They last from seven to twelve days, and if their contents have 
not been evacuated, they either dry up after the serum has 
been absorbed, or else form little scabs, which soon fall ofl". 

When the vesicles have disappeared, the red and inflamed 
patches, by a gradual subsidence of the redness and inflamma- 
tion, soon return to their normal color and condition. For 
some time after the skin has regained its normal condition, 
there still remains the acute neuralgic pain, though less in se- 
verity, and this pain is very annoying until it finally disappears. 
The eruption may appear simultaneously at the opposite ends 
of the nerves, and by successive formation of new vesicles and 
patches, gradually approach, until they finally coalesce. It 
rarely appears a second time in the same subject, one attack 
generally securing complete immunity against another. 

Diag7iosis. — Zoster, from its characteristic symptoms, can 
hardly be mistaken for any other skin disease, but it is some- 
time confounded with herpes, and may be differentiated as fol- 
lows: herpes has a tendency to recur and generally appears on 
both sides ; zoster rarely, if ever, appears twice in the same 
subject, and is usually unilateral ; herpes follows in the wake 
of some catarrhal affection of the mucous membranes, and in 
most cases, is confined to the face and genitals ; zoster is due 
to some neuritis, and follows the course of some nerve or 
nerves ; herpes is preceded and accompanied by a burning itch- 
ing, and never leaves cicatrices ; zoster is attended by a more 
or less severe neuralgic pain, and often leaves scars to mark the 
site of the eruption. 

Prognosis. — As zoster is not of itself a dangerous or fatal 
disease, the prognosis is always favorable. Children usually 



ZOSTER. 783 

recover rapidly, and neuralgia, even if present during the at- 
tack, is seldom persistent, as it is apt to be in adults and espe- 
cially in the aged. 

Treatment. — The first indication in the treatment of zoster 
is the alleviation of the pain, and this is best accomplished by 
the use of the galvanic current. The current should be used 
as strong as can be borne, or about six cells, and should be ap- 
plied from ten to fifteen minutes daily. The local treatment 
consists of protecting the vesicles from external irritation, by 
coating them with flexible collodion or traumaticin, cantharides 
ointment, or dusting over them equal parts of starch and sub- 
nitrate of bismuth, and then over this applying a roller band- 
age. 

The indications for the remedies are as follows : 

Rhus tox. — Sleeplessness, with restless tossing about ; vesicles 
are confluent, small, painful, burning and surrounded by red 
skin ; pain aggravated by scratching ; worse in cold weather ; 
disease brought on by getting wet while overheated. 

Arsenicum. — Intense burning pain; vesicles confluent and 
very small; intense, cutting, burning neuralgia; great thirst 
and exhaustion ; aggravated at night and by cold applications. 

Graphites. — Skin dry and with a tendency to ulcerate; large 
vesicles following course of intercostal nerves; burning when 
touched, and worse from warmth ; zoster of left side. 

Mercurius. — Vesicles involving greater part of one side of 
abdomen, especially the right ; tendency to suppuration ; ag- 
gravation at night, and from warmth of bed. 

Zinc. — Acute neuralgic pains ; aggravation at night and after 
eating ; better from being handled. 

Zinc phos. — After other remedies have failed, often works 
wonders. 



CHAPTER VI. 

ERYSIPELAS (ST. ANTHONY'S FIRE). 

Definition. — Erysipelas is an acute, contagious, specific in- 
flammation of the skin and subcutaneous connective tissue, 
characterized by an eruption or deep-red rash, accompanied by 
a peculiar pungent, burning pain, and heat and swelling. A 
great, or marked, characteristic of erysipelas is its tendency to 
spread and infect other portions, the primary seat healing, 
while the newly invaded surface is becoming affected. The 
disease is variable both as to its extent and severity ; and ac- 
cording to its extent and severity, it will terminate in resolu- 
tion, suppuration or gangrene. 

It is rarely ever met with in childhood, and when such cases 
are seen they present no differences, or at least have nearly the 
same features, as the disease when occurring in adults; but on 
the other hand it is a common affection during infancy, espe- 
cially common in infants under six months of age ; for in forty 
consecutive cases occurring in infants, twenty-seven were under 
six months, eight between six and twelve months, and the re- 
maining five over twelve months. The disease as seen during 
this period, presents quite a number of distinctive features that 
differ materially from that which occurs in adult life. 

It is seldom met with in families in easy circumstances, but 
is very common among the poor, where proper attention is not 
devoted to the requirements of cleanliness ; and in crowded 
houses, especially in lying-in hospitals, children's homes and 
foundling asylums. 

The course of the disease is often irregular, and the physician 
may be priding himself on the apparent success of his treat- 
ment, when suddenly it will break out again with renewed 
vigor, reinfecting the lately healing parts, set up a more viru- 
lent inflammation than before, and speedily carry off the pa- 
tient from exhaustion. Thus it will be seen that one attack 
is no security against another, but, rather, leaves the system 
in a debilitated state that is susceptible to a reinfection of the 
disease. 

In the adult, the favorite point of infection is undoubtedly 
the head or face, while in infancy they are seldom starting- 
(784) 



ERl'SIPELAS (ST. ANTHONY'S FIRE). 785 

points. In thirteen out of twenty-six cases occurring in female 
children, the point of invasion was the vulva, while in fifty- 
eight cases of both sexes, thirty-four, or sixty per cent., the 
vaccination site was the commencement, and from this it is evi- 
dent that the vulva and vaccine pocks are the favorite places 
of invasion, while the male genitals are rarely the beginning, as 
are also the arms, legs, nates and feet. 

Etiology. — Erysipelas must be regarded as a specific disease, 
inasmuch as it depends upon the entrance into the system of a 
specific micro-organism, called the Streptococcus erysipelatis. 

This pathogenic micro-organism spreads by the lymphatic 
channels of the skin, penetrates into the tissues, forms chains 
or swarms of cocei, and excites a specific inflammation and 
leads to tissue necrosis. 

The causes that favor the development of erysipelas have by 
common consent been divided into two classes, viz.: predispos- 
ing and exciting. 

The most powerful predisposing cause of this malady in the 
abstract is traumatism. It is mostly a disease of the temperate 
zone, and occurs more frequently in the colder than in the 
warmer months of the year. It is particularly prevalent in 
damp, changeable weather, with unstable temperature. 

Uncleanliness and improper food, living in damp, dark, 
crowded and illy-ventilated rooms, and especially overcrowding 
in hospitals, as during the existence of other epidemics, furnish 
conditions favorable to the development of the disease. It 
spreads for the most part by direct contagion, and when once 
established in a house or in a public institution, it may develop 
upon even the most trivial break of the surface — abrasions, fis- 
sures, etc. — in susceptible individuals. 

Vaccination is one of the most prolific of the exciting causes, 
and often the abrasion and the inflammation, which necessarily 
arise around the point of operation, are the cause of it, and not 
any deleterious quality contained in the virus, as is supposed 
by many ; and this is well borne out by the fact that the in- 
flammation involving a burn or wound, may be followed by 
similar results. In children, on account of the difficulty of 
dressing and caring for operations, the wounds, in most vac- 
cinations, are followed by some degree of erysipelatous inflam- 
mation. 

When occurring in the very young, it is principally associ- 
ated with the separation of the cord. It often follows closely 
upon some other inflammatory condition of the surface, as the 
irritated folds of the skin in intertrigo, etc., or when the thin 
portions of the cuticle are fissured, as at the corners of the eyes, 
nostrils, mouth, arms and vulva. Arnica, rhus tox., belladonna^ 
D.C.— 50 



786 THE DISEASES OF CHILDREN. 

and other drugs, whether used externally or internally, will, if 
used in sufficiently large doses, set up an attack of this disease. 
From the greater percentage of cases that have their origin at 
or near the vulva, it may be readily inferred that female chil- 
dren are more liable to it than the male. 

In his " Treatise on Diseases of Children," Dr. Condie says 
of the connection of puerperal fever and erysipelas : *' Erysip- 
elas of infants very commonly occurs during the prevalence of 
epidemic puerperal fever. Children of mothers who become 
affected with the fever are often born with erysipelatous in- 
flammation ; others are attacked almost immediately after birth. 
Whether, in these cases, the disease is to be referred to a mor- 
bid matter applied to the skin in the womb, or to the same ep- 
idemic or endemic influence which gives rise to the disease of 
the patient, it is difficult to say. According to M. Trousseau, 
infantile erysipelas is principally observed when puerperal fever 
prevails in the wards of the lying-in hospitals in Paris." 

In private practice, few cases of infantile erysipelas, associ- 
ated with erysipelas in the mother, are met with, but when 
puerperal fever and erysipelas are epidemic it occurs more fre- 
quently. 

That the disease is spread by carelessness in the handling of 
infected subjects and the dressings, direct contagion and inoc- 
ulation, is well known ; and as the disease is so highly contagious, 
all patients suffering from it should be isolated as much as pos- 
sible, the dressings and bandages destroyed immediately after 
removal, and the nurse should disinfect herself before coming 
in contact with other members of the family. 

Symptomatology. — Infantile erysipelas is in some cases pre- 
ceded by an incubative stage, but these are few in number, 
and this, with the lack of facilities for observation, makes it al- 
most impossible to determine the length of this stage. It is 
usually ushered in with slight rigors, drowsiness, or, in some 
cases, extreme restlessness, twitchings of the flexor and exten- 
sor muscles, increased temperature, rapid pulse, and sometimes, 
nausea and vomiting. With the onset of the eruption all the 
symptoms intensify ; and, in the majority of cases, there is ex- 
treme restlessness caused by the peculiar pungent, burning pain 
accompanying it. When it appears the fever increases, some- 
times as high as 104° or 105°, or even 106°, pulse very rapid, 
often 160 to 180 per minute ; there is considerable thirst, stom- 
ach is irritable, bowels irregular and frequently in a diarrheic 
condition, the face is flushed, the entire cutaneous surface is 
hot to the touch, the tongue is furred, and sleep is impossible 
from the burning pain. In the severe cases convulsions have 
been observed, but as a rule they do not occur. 



ERTSIPELAS (ST. ANTHONY'S FIRE). 787 

If it occurs at or near the umbilicus, or in the neighborhood 
of the inflamed patches of intertrigo or vaccinations, it spreads 
very rapidly, the invaded skin becoming infiltrated and swollen, 
and at the points of most intense inflammation, vesicles may 
form, and these points may be followed by gangrene with 
sloughing of large areas, but, most frequently, they terminate 
in desquamation. 

Peritonitis is a complication quite common when the um- 
bilicus is the point of infection. This is a result of perforation 
of the abdominal wall by the gangrene and sloughing induced 
by the severity of the inflammation. The peritonitis is septic 
and is usually, and often very quickly, fatal. 

Abscesses may occur and remain in an inflamed condition 
some time after all traces of inflammation in the surrounding 
skin have disappeared. If situated at or near the umbilicus, 
they should be carefully watched, for if they discharge into the 
peritoneal cavity, serious results will follow. 

The great characteristic symptom of erysipelas is its tend- 
ency to spread, and, unlike other diseases, instead of one attack 
immuning against another, it predisposes the skin to a repeti- 
tion, and these facts should be borne carefully in mind, and the 
case followed some time after all symptoms have ceased, for it 
may suddenly be relighted in a more malignant form and 
speedily carry off the already exhausted little one. 

The duration of the disease varies with the intensity of the 
inflammation. If the attack be light and uncomplicated, the 
inflammation usually lasts from seven to ten days, but some 
cases may be prolonged for months. In fatal cases, however, 
death occurs on an average of twelve days after the appear- 
ance of the eruption, and in most of them death occurs from 
exhaustion. 

Diagnosis. — In the earliest stages, the diagnosis of erysipelas 
is an impossibility ; but when the eruption appears, the peculiar 
burning pain, the characteristic spreading, etc., are sufficient to 
decide the diagnosis. It closely resembles erythema, scarlet 
fever, herpes, zoster, and eczema ; but a delay of a few hours 
or even a day, will be rewarded by enabling a positive diagno- 
sis to be made. 

Prognosis. — Age has a great influence in the prognosis of this 
disease. In very young infants it is almost always fatal. 
When occurring in babies between the age of one and six 
months, the prognosis should be guarded, but in infants over 
six months, and the attack being light, it may generally be pro- 
nounced favorable. However, with the tendency of the dis- 
ease to recur in severer forms, and in already over-taxed pa- 
tients, the prognosis should, in all cases, be guarded, and this is 



788 THE DISEASES OF CHILDREN. 

especially true when those who are naturally weak and debilU 
tated are affected. 

Treat7nent. — When a positive diagnosis has been made, 
prompt measures should be taken at once to prevent its spread, 
and this is best accomplished by either bandaging the diseased 
portions, or removing the patient to a room where it can be 
isolated from other members of the family. In all cases, no 
matter how simple, strict antiseptic precautions should be ob- 
served, both to prevent auto-inoculation and otherwise spread- 
ing the disease. 

The first and most important consideration in the treatment 
is, if possible, to prevent the disease from spreading, and invad- 
ing other portions of the skin. Various methods have been 
advocated for the purpose of circumscribing the inflammation, 
and in our estimation the best in use, at the present, is the ap- 
plication of the tincture of iodine. This is accomplished by 
painting a circle of the tincture, an inch in width, around the 
margins of the inflamed area. 

Irrigating the invaded surfaces with antiseptic washes, or the 
application of cold compresses of calendula, hamamelis, hydras- 
tis, veratruni viride, or of weak solutions of carbolic acid, mer- 
cury, etc., will relieve the burning pain and irritation ; while 
rye or buckwheat flour dusted over the diseased patches is very 
cooling. 

If the child is weak and poorly nourished, some one of the 
various infant foods, that after repeated trials is found to agree 
with the patient, should be given. If the bowels are irregular, 
they should be attended to and restored to their normal condi- 
tion. A change from the crowded and illy-ventilated tenement 
houses to a place where more room, sunlight and freedom can 
be obtained, will be highly beneficial. If the disease is conse- 
quent upon a vaccination, washing with atwo-per cent, solution 
of carbolic acid and dressing with Hydrastis, with the internal 
administration of ars., bell., or rhus tox., whichever is best indi- 
cated, will be followed by a prompt improvement. When ab- 
scesses threaten, belladonna will, if administered in time, abort 
them ; otherwise, they should be encouraged to point, by heat, 
hepar sulph., etc., and then opened freely with a bistuory. For 
the further consideration of those cases that require surgical 
treatment, the reader is referred to the standard homeopathic 
works on surgery. 

Following are the indications for the remedies: 

Rhus tox. — Great restlessness and uneasiness ; twitching and 
jerking of the muscles; itching over the whole body; stools, 
thin, loose and dark brown ; pulse very rapid, small and weak ; 
fever with chilliness; worse at night; vesicular eruption. 



ERl'SIPELAS (ST. ANTHONT'S FIRE). 789 

Apis. — Skin swollen, dry and mottled ; eruption intense, deep 
red, and accompanied by severe stinging, smarting pains ; 
edematous swelling of the extremities ; stools copious, yellowish, 
and occur with every movement of the body ; pulse small, rapid 
and wiry ; fever without thirst ; tongue furred. 

Arnica. — Face and eyes sunken; tongue coated white; vom- 
iting of food, no appetite, great thirst ; diarrhea, stools involun- 
tary, while asleep, undigested, painful, causing patient to scream 
and cry out ; skin red, hot and painful, edematous ; inflamma- 
tion of skin and cellular tissues, very painful to the touch; feet 
and hands cold, but body very hot. 

Arsenicum. — Great restlessness; violent thirst; vomiting; 
diarrhea, stools black or dark green, offensive and excoriating ; 
skin cold and clammy, with gangrenous aspect ; exudation of 
thin, colorless, acrid, very offensive fluid ; typhoid symptoms. 

Belladonna. — Convulsions; eyes widely dilated ; violent throb- 
bing of the carotids; face red and hot; excessive thirst, vomit- 
ing, tongue white with red edges ; stools slimy, with offensive 
odor; skin red, hot and shining; eruption smooth, red and hot ; 
great sensitiveness of entire skin ; pulse full, hard and rapid ; 
high fever, with rigors. 

Cantharis. — Vesicular eruption, burning and stinging ; child 
cries, screams or has spasms when urinating; especially useful 
after the too free use of arnica externally. 

Lachesis. — Eruption becomes dark blue, black or mottled ; 
gangrene; ulcers foul and angry looking; convulsions; restless 
tossing about, with moanings; thirst, loss of appetite, and vom- 
iting ; stools sudden, copious, watery, dark and very offensive; 
pulse rapid and irregular. 



CHAPTER VII. 

IMPETIGO CONTAGIOSA (PORRIGO CONTAGIOSA). 

Definition. — Impetigo contagiosa is an acute, contagious in- 
flammation of the skin, characterized by an eruption of vesicles 
and pustules, and accompanied by more or less pruritis. The 
vesicles and pustules are minute points appearing in clusters or 
patches, or else scattered singly over the surface. When occur- 
ring in patches, the vesicles and pustules are closely aggregated, 
and when broken and their contents discharged, one large 
crust or scab is formed, which varies in size from a split pea to 
a common marble. This crust is yellowish or straw-colored, 
has ridges and excavations on the surface, giving it an umbili- 
cated appearance, and looks much as if it was " stuck on " the 
skin. 

The pus from the pustules is highly contagious and is also 
auto-inoculable. The disease is spread by direct contagion and 
by inoculation. It occurs mostly on the extremities, but is 
frequently seen on other portions of the body. When occur- 
ring on the arms the pustules are smaller and rounded, while 
those on the lower extremities are large and more elliptical. 

Etiology. — Impetigo contagiosa is chiefly seen among the 
poor, and is most frequent in children under seven years of 
age. It is due to the inoculation of contagious pus, independ- 
ently of its source. The staphylococcus awrens is the most 
common pathogenic organism of this affection. Kissing, as be- 
tween children and parents, may carry the disease, and not un- 
commonly several cases are met with in the same family. 

Symptojnatology. — The eruption is usually preceded by a 
period of incubation which lasts from three to five or six days. 
The prodromal symptoms are : fever, rapid, small, weak pulse, 
loss of appetite, diarrhea or constipation, restlessness and sleep- 
lessness. After the third day the eruption generally makes its 
appearance, consisting of numerous fine vesicles situated on an 
inflamed surface, having well-defined margins. When first 
formed the vesicles are very small but rapidly enlarge and de- 
velop into pustules. They are slightly raised from the surface, 
and, at first, are filled with a transparent fluid, which in a few 
days undergoes suppuration. 

Soon after the formation of the pustules they break and their 
(790) 



IMPETIGO CONTAGIOSA. 791 

contents are exuded over the skin, where the pus slowly forms 
thick, yellow scabs or crusts, while from under the edges of 
which the undried pus is being constantly exuded. 

In mild cases the eruption is limited in extent, but in severe 
cases, and especially those that have been neglected, the entire 
extremity or extremities may be involved to such an extent as 
to have its motion and utility interfered with. When the ex- 
tent of the eruption is very great, there are generally numerous 
cracks or fissures in the crusts, through which pus is constantly 
exuding, and, drying on the old scabs, tends to increase their 
thickness to an enormous extent. It often happens that the 
nails are involved when the eruption has extended to the hands 
and feet, and, when so involved, they usually drop off and are 
replaced by irregular and distorted new ones. 

With the appearance of the vesicles, a sensation of heat, 
itching and smarting is felt, which varies in degree, according 
to the mildness or severity of the inflammation, and the extent 
of the eruption. The duration of the disease varies with the 
subject, lasting in some two weeks, while in others it may be 
prolonged, by auto-inoculation, for six and even eight months. 

After their formation, the crusts generally last from ten to 
fourteen days, when they begin to exfoliate. When they have 
loosened and fallen off, the healing process is unhindered and 
proceeds very rapidly, beginning at the center of the patch, 
and gradually working towards the circumference. In some 
cases, a few, small, round, elevated spots, situated on red 
patches, are seen after the crusts have exfoliated, but they soon 
disappear. 

Diagnosis. — Impetigo contagiosa is most liable to be con- 
founded with eczema, scabies and varicella. It can be diag- 
nosed from pustular eczema by the fact that the eczematous 
eruption is more confluent, excites intense itching, and is usu- 
ally associated with inflammation and infiltration of the sur- 
rounding skin ; from scabies by the multiformity of lesions, 
the intense itching, and the presence of acari, in the latter, and 
from varicella by the more numerous and smaller lesions of 
chicken-pox, and their distribution over almost the entire body. 

Prognosis. — The prognosis is generally good. Under favor- 
able conditions the disease will terminate spontaneously in two 
or three weeks. It may be prolonged for an indefinite period 
by auto-inoculation, but is never dangerous to life. 

Treatment. — As the disease is so highly contagious, means to 
prevent the patient from scratching, as well as its spreading, 
should be taken at once ; and this is best accomplished by 
gently pressing out all the pus, removing the crusts with warm 
carbolic acid solutions and applying antiseptic compresses. 



792 THE DISEASES OF CHILDREN. 

After the removal of the crusts, the raw and inflamed sur- 
faces should be anointed with some emollient substance, such 
as olive-oil, vaselin, etc. If the case is a mild one, this is all 
the treatment that will be necessary ; but in severe and exten- 
sive cases the constitutional symptoms demand attention. 

The diet should be carefully looked after, and the patient, if 
exhausted, given a stimulating and highly-nourishing diet. Ab- 
solute cleanliness is indispensable, as is also plenty of good, 
pure, fresh air, and sunshine. The crusts should be removed as 
fast as formed ; and if there is much pruritis, dusting the sur- 
face with equal parts of starch and zinc oxid (the greater the 
extent of raw surface, the more starch in proportion to the zinc 
should be used), or buckwheat flour will be very effective. Good 
results often follow the use of an ointment consisting of five 
per cent, of resorcin in equal parts of lanolin and vaselin. In 
all cases the discharges should be removed as they form. 

The remedies are indicated as follows: 

A^itinioniiun criid. — Nausea, vomiting; no appetite; vesicles 
and pustules burn and sting; eruption mostly on face, with 
brown, scurfy skin between the patches. 

Antimoniiim tart. — Excessive restlessness ; child trembles all 
over; weakness and prostration; eruption, pustular, thick, and 
as large as a pea ; eruption leaves painful, bluish-red marks on 
the face. 

Kali bicJi. — Extreme weakness; restless; pains shoot from 
one patch to another; nausea, worse in morning; pustular erup- 
tion confined to forearms; pustules are round and regular in 
shape, and very painful. 

Thuja. — Trembling of the upper extremities ; emaciation and 
weakness; burning stitches in various parts; very restless; 
sleeplessness; eruption mostly on lower extremities; especially 
useful when the disease occurs after vaccination. 



CHAPTER VIII. 

URTICARIA (nettle-rash ; HIVES). 

Definition. — Urticaria is a non-contagious, inflammatory con- 
dition of the skin, characterized by an eruption consisting of 
rapidly-formed evanescent wheals of a whitish or reddish color, 
accomipanied by more or less burning, tingling and itching. 

The lesions vary in size from a quarter to one inch in diame- 
ter, occur in patches, and are distributed here and there over 
the cutaneous surface. The number of wheals varies on differ- 
ent parts of the body, being most numerous on the arms; and 
it is more their size and not their number, that gives size and 
extent to the patches. 

These patches are surrounded by inflammatory zones, which 
have well-defined margins ; and the inflammation varies in 
severity, as does also the accompanying pruritis and burning, 
according to the extent of these patches. The inflammation 
rarely lasts any great length of time, generally disappearing 
entirely in forty-eight hours, while even in some cases the pro- 
cess may have ceased in an hour. All symptoms usually dis- 
appear in five or ten days. 

The characteristics of the wheals presented to the eye are 
their red, white, or reddish-white color, their varying size and 
irregular shape, their occurring in patches, and the well-marked 
border of inflammation surrounding the patches ; while to the 
touch, they are hard and elevated somewhat above the surface 
of the skin, and their surfaces are uneven. To the eye and 
touch, they are almost identical with the wales produced by a 
strong blow with a switch on the skin. The common name of 
urticaria is nettle-rash, while it is sometimes called hives. 

Etiology. — The causes of urticaria may be divided into two 
classes, viz. : predisposing and exciting. 

The most important among the predisposing causes, is a 
weak and delicate skin, that, under each and every irritation, 
no matter how slight, is ever ready to take on some form of 
inflammation, and this inflammation, acting in conjunction with 
proper exciting causes, will eventually become an urticaria. 

This susceptibility of the skin is so marked in some children, 
that even the taking of certain substances into the mouth will 

(793) 



794 THE DISEASES OF CHILDREN. 

cause an eruption of the disease, and we can cite a case of a 
ten-year-old boy, who, at one time, had no sooner taken a piece 
of strong cheese into his mouth, than his face became intensely 
red, and this hyperemia was soon followed by wheals, which 
lasted nearly thirty-six hours, when they finally disappeared. 

Anger, fright, or some other intense mental excitement has 
produced it. Seasons also have considerable influence in its 
causation, as the majority of cases occur late in spring or early 
summer. Excessive clothing, over-heated rooms and too 
frequent bathing produce a tendency to its appearance. 

Among the exciting causes that are to be mentioned first, are 
those that act from within. The most important of these are 
such substances that, when taken into the irritable stomach, 
nearly always found accompanying a delicate skin, will set up 
reflex action and irritate the skin ; such substances are bella- 
do7iJia, broinin, cantkarides, iodin, rJius tox., turpentine, etc., 
and in addition to these are to be mentioned, rich pastry, highly 
seasoned foods, strong cheese, lobsters, oysters, crabs, canned 
and salted fish and meats, pickles, strawberries, oily nuts, 
olives and other fatty foods. Worms and chronic intestinal 
catarrh are common causes in children. 

The exciting causes acting from without are : various me- 
chanical injuries, such as falls, blows, bruises, whippings ; tight 
clothing and shoes ; irritations of orthopedic instruments ; bites 
of different insects, as fleas, mosquitoes, bed-bugs, spiders ; 
stings of bees, wasps, hornets, etc.; and some drugs applied ex- 
ternally. The most common external cause is the scratching 
induced by itching from whatever source. It may exist in con- 
nection with other skin diseases, and, when so existent is the 
result of the scratching ; while in some cases it may be so ex- 
tensive as to entirely mask the primary disease, making diag- 
nosis of that affection impossible. 

Symptomatology. — Urticaria, when occurring in the adult, is 
ushered in with high fever and more or less febrile disturbance ; 
and it is this that distinguishes urticaria occurring in the adult 
from that which occurs in infancy, for the latter has no fever 
and only slight febrile movement. The onset of the eruption 
is generally preceded by symptoms of headache or congestion, 
great restlessness, weakness and languor, vomiting, variable 
condition of appetite and bowels, tongue thickly coated white, 
and irritableness. In some few cases there are no prodromic 
symptoms, the eruption being ushered in with a most intense 
pruritis and burning which causes the child to lose all self-con- 
trol and give way to paroxysms of scratching. 

The eruption consists of papules or small tubercles about the 
size of a split pea, and of a red or white color. The papules 



URTICARIA ^NETTLE-RASH; HIVES). 795 

are congregated in groups or clusters, of a dozen or more, 
and are surrounded by bands of inflammation with well-defined 
margins ; and these patches vary in size, are irregular shaped, 
and are distributed over the surface either singly or in clusters. 
When the patches occur in clusters, the papules have a ten- 
dency to coalesce and form one large wheal, which is generally 
of a greater length than breadth. 

The extent of the eruption varies in different individuals, but 
it is usually limited to the face, arms, back and thighs, although 
it may involve the entire skin. In the center of the papules 
are white spots, which, when punctured, exude a thin colorless 
fluid. The eruption rarely lasts over forty-eight hours, and 
ends in a slight desquamation. The papules that are first formed 
do not last long, but disappear in a few hours, and are replaced 
by others, on different parts of the body or on the same site. 
So fugitive is the character of the eruption, that by the time 
the physician responds to the first call, it may have entirely 
disappeared, leaving only the marks produced by the scratch- 
ing. The wheals, when ruptured by scratching, bleed slightly, 
which, drying, form little scabs on their apices. 

Diagnosis. — The diagnosis of urticaria is exceedingly easy, as 
it can hardly be mistaken for any other disease. The evanes- 
cent character of the eruption, the agonizing pruritis, and the 
hard, elevated, white or red wheals are met with in no other 
skin disease. Dermatitis contusiformis, however, has many of 
the features of urticaria, but it can be differentiated by the 
regular course, intense hyperemia, regularity of shape of no- 
dules, and the entire absence of pruritis of the dermatitis. 

Prognosis. — There are no cases on record, where death has 
been the direct result of urticaria. It is an exceedingly mild 
disease, and the prognosis is always favorable, although among 
the poorer classes, where proper hygienic measures cannot be 
enforced, the disease may be prolonged indefinitely. It has no 
dangerous symptoms, and when such are present, are always 
dependent upon the gastric disorder or whatever produced the 
disease. The papular form in children often proves very ob- 
stinate. 

Treatment. — The first and most important point in the treat- 
ment, is the removal, if possible, of the cause of the eruption. 
If it be the result of an over-loaded stomach, the stomach 
should be emptied by a gentle emetic. If due to diarrhea or 
constipation, the bowels should be carefully attended to and 
returned to their normal condition. All errors of diet, clothing, 
etc., are to be corrected. If, for some reason, the child is in a 
constant state of nervous tension, steps to the removal of the 
nervousness should at once be taken, and the child kept as 



796 THE DISEASES OF CHILDREN. 

quiet as possible. When occurring in little boys with phymo- 
sis, they should be circumcised immediately, the sooner the 
better. In little girls, the hood of the clitoris, if adherent, 
should be loosened, and all smegma thoroughly removed. If 
due to a filthy condition, whereby body lice are contracted, ab- 
solute cleanliness should be insisted upon, which will, in most 
cases, be destructive to the lice. 

After all causes have been removed, the attention should be 
directed to the alleviation of the pruritis, and this is best ac- 
complished by irrigation with some alkaline or antiseptic solu- 
tion. If the eruption be simply local or of small extent, two 
per cent, carbolic acid or bi-chlorid mercury, one to two thou- 
sand may be used. If the skin be unbroken, the patches may 
be washed with warm salt water. Buckwheat or rye flour, or 
equal parts of oxid of zinc and starch, dusted over the patches, 
has a decided anti-pruritic action. 

In all cases, strict cleanliness should be observed, and the 
diet carefully watched, so that if the eruption is due to some 
improper food, that article can be detected and at once removed 
from the child's regimen. If the patient be weak and debili- 
tated, a good stimulating as well as nourishing diet should be 
ordered and given in such quantities as best suits the demands 
of the system. Outdoor exercise and plenty of fresh air and 
sunshine are very beneficial. 

The remedies are indicated as follows : 

Apis met. — Tired, weak, languid, with trembling of the limbs; 
the eruption stings and burns like stings of bees, wasps, hornets 
and other insects; eruption intensely red, and pruritis worse at 
night ; eruption spread over nearly entire body. 

Arsenicum alb. — Intense thirst, great restlessness and sleep- 
lessness; eruption of a deep-red color, and confined to face and 
arms ; the eruption burns, is exceedingly painful, and is aggra- 
vated by scratching; wheals greatly enlarged by scratching. 

Belladomia. — Symptoms of congestion of head ; tongue red, 
with white streak in center; skin hypersensitive; eruption of a 
bright-red color, surrounded by deep-red border ; burning and 
itching comes and goes periodically and suddenly. 

Calcarea carb. — Child weak, muscles flabby, and skin very 
unhealthy; eruption tends to become chronic; the eruption is 
hard, very light colored, elevated and situated on white surface, 
and disappears on going out in open air. 

Cina. — Digging and scratching at the nose ; twitching and 
jerking of the muscles; eruption first appears about the nostrils 
and from there spreads over face and back ; eruption from worm 
troubles. 

Conium. — Child takes cold very easily ; is weak and easily^ 



URTICARIA {NETTLE-RASH; HIVES). 797 

exhausted; eruption mostly on back and thighs; pruritis and 
stinging like bites of insects ; aggravation at night and from 
scratching. 

Graphites. — In weak, thin, poorly-nourished children ; the 
eruption is spread over entire body ; itching and burning ag- 
gravated by scratching and at night ; sour-smelling perspira- 
tion when warm in bed, or skin is dry with tendency to fissure. 

Podophyllum. — Tongue heavily coated white ; diarrhea, with 
dark-green, watery stools, passed with much flatus ; is very 
sleepy during the morning, but wakeful at night ; eruption con- 
fined to back and arms; intense pruritis unrelieved by scratch- 
ing ; eruption aggravated by scratching. 

Pulsatilla. — Eruption caused by eating pastry, fatty foods, 
highly seasoned articles, etc. ; itching very evanescent, rapidly 
shifting from one spot to another; eruption is red, elevated 
and very hot ; scratching slightly relieves pruritis, which is 
aggravated from warmth of bed. 

Ruta. — Nausea and vomiting brought on by drinking milk ; 
constipation with rumbling in bowels ; eruption brought on by 
eating meat ; intolerable pruritis all over the body, aggravated 
by cold air, but relieved by scratching. 

Sulphur. — Weakness and languor; aversion to washing; of- 
fensive smell from child who is exceedingly dirty; eruption 
frequently due to body lice ; eruption on whole body ; burning 
and itching relieved by scratching, but worse from warmth of 
bed ; especially useful in chronic cases. 

Zinc met. — Child dull, stupid and greatly emaciated ; muscles 
twitch and jerk; itching seems to be between skin and flesh; 
the eruption appears immediately after eating or taking a bath. 



CHAPTER IX. 

TRICHOPHYTOSIS (RINGWORM). 

Definitioii, — Trichophytosis is a contagious affection of the 
skin due to the development of the trichophyton fungus in the 
hairs, hair-follicles and epidermis. 

As observed in children, it may be most conveniently de- 
scribed under the regional forms of trichophytosis corporis or 
ringworm of the general surface, and trichophytosis capitis or 
ringworm of the scalp. 

Etiology. — Trichophytosis is caused by the trichophyton, a 
vegetable parasite which consists of spores and mycelia, but 
especially of spores. It is highly contagious, and is readily 
communicable, either directly from one person to another, or 
through the medium of wearing apparel, or of the various arti- 
cles of the toilet. 

It is met with in the horse, dog, cat, cow, rabbit, and other 
domestic animals, and may be transmitted by them to man. 

Trichophytosis capitis is most common in fair-haired, poorly- 
nourished children. It is seldom met with in infancy, or after 
puberty. 

Trichophytosis corporis may occur at any age, but is uncom- 
mon after fifty. It is of more frequent occurrence in children 
than in adults. 

Symptomatology. — Trichophytosis corporis is more common 
upon the face, neck, arms and exposed parts, but may appear 
upon any part of the body. It begins as a small, light-red, 
slightly scaly spot, presenting a circular, sharply-defined, 
slightly elevated border, which may be either papular or ve- 
sicular. As the spot increases at the periphery, it frequently 
displays a tendency to clear up in the center, and the lesion as- 
sumes a ring-shape appearance. Not infrequently pale-red, cir- 
cular, well-defined, scaly patches, which extend centrifugally, 
but do not clear up in the center, are observed to take the 
place of, or occur in connection with, the more typical ring for- 
mations. The patches or rings may be one or several, ordina- 
rily but two or three are present. They may attain the size of 
a half inch or larger, and may remain separate or coalesce and 
form gyrate or crescentic figures. They give rise to bui little 
(798) 



TRICHOPHTTCSIS {RINGWORM). 799 

physical discomfort, other than slight itching, and may con- 
tinue for days, weeks, or months, if allowed to remain untreated. 

Ringworm of the body may coexist with ringworm of the 
scalp. 

Trichophytosis capitis is almost exclusively confined to chil- 
dren. Not infrequently it prevails in schools and public insti- 
tutions as an epidemic. It begins around a hair, as a red point 
which increases peripherally, and soon becomes a well-defined 
pale or grayish-red patch, covered with fine, white scales. Us- 
ually attention is first directed to the affection by the presence 
of one or more, generally circular, variously-sized patches with 
sharply-defined borders, covered with ashen-gray scales and 
stumps of dull, lusterless hair. It may remain limited to one 
or more spots, or invade the entire scalp. Sometimes it be- 
comes disseminated, and may then readily escape detection, as 
the scaliness is slight and the stumps are few. Occasionally it 
shows a tendency to spread beyond the line of the hair and 
down upon the adjacent uncovered skin. After it has existed 
for some time the patches may assume a bluish or slate-colored 
appearance. Itching in various grades of severity, though 
usually mild, is commonly present. 

Early in the disease, the hairs undergo alterations, and become 
bent, twisted and brittle. The broken hairs are of a lighter 
color than the neighboring healthy hair, and their extremities 
are ragged and often brush-like. In very fair, fine-haired chil- 
dren, the hairs, instead of sticking up, are apt to lie close to the 
skin, and appear thickened and matted. On attempting to ex- 
tract the short hair-stumps with the epilation forceps, it will be 
found that many of them break off, leaving the root in the fol- 
licle. Under the microscope, with the power of three or four 
hundred diameters, an extracted hair-stump, after being soaked 
in a few drops of liquor, and then potassae, will be seen to be 
stuffed with the minute spores of the trichophyton. The ash- 
en-gray scales of the affected scalp are found to exhibit traces 
of the fungus, though to a less extent than the invaded hairs. 
The hair-shaft is often longitudinally split, the growth of the 
parasite having forced the elements apart. 

Trichophytosis capitis may be either acute or chronic, and 
when left to itself it may persist indefinitely. 

Pathology. — The seat of the trichophyton fungus is in the 
hair, hair-follicles and epidermis, where, by its development, it 
produces the various clinical appearances of the disease. 

Diagnosis. — The diagnosis of trichophytosis, in typical cases, 
is usually easy. The peculiar clinical features in ringworm of 
the body, especially the rapid development of the circles, with 
a tendency to clear up in the center, and the presence of bent, 



800 THE DISEASES OF CHILDREN. 

broken and twisted hair-stumps in ringworm of the scalp are 
sufficiently characteristic. In all forms, the discovery of the 
trichophyton fungus in the scales and hairs will establish the 
diagnosis with certainty. 

The only diseases with which it is liable to be confounded, 
are seborrhea, psoriasis and alopecia areata. 

In seborrhea the scaliness is diffuse, and the thinning of the 
hair, when present, is general, and there are never any broken- 
oiT hair-stumps. 

In psoriasis the scales are more abundant than in trichophy- 
tosis, the patches are more symmetrically distributed, and there 
are never any short stubbly hairs. 

In alopecia areata the hairs fall out entire, leaving patches or 
bands of perfectly bald, smooth, white skin. Where there is 
doubt, recourse must be had to the microscope. 

Prognosis. — While the prognosis in all forms of ringworm is 
usually favorable, it should be guarded as to the length of time 
required to affect a cure. Trichophytosis corporis is generally 
curable in one or two weeks, while trichophytosis capitis is rarely 
cured within four or six months. 

Treatment. — The treatment of trichophytosis, when the dis- 
ease is superficial, as in ringworm of the body, is easy and 
promptly curative ; while that of ringworm of the scalp is tedi- 
ous, owing to the mechanical difficulty of carrying the parasiti- 
cide deeply enough to reach the fungus in the hair-follicles. 

In trichophytosis corporis the scales should be removed 
with soap and hot water, and the lesions well rubbed twice a 
day with almost any antiparasitic ointment, preferably one 
composed of sulphur one drachm, carbolic acid twenty minims, 
lanolin five drachms, and olive oil three drachms ; or an oint- 
ment of ammoniated mercury, fifteen to forty grains to the 
ounce of lanolin and olive oil or lard. A few applications of 
tincture of iodin or of dilute acetic acid often prove effective. 
Ordinary writing-ink, and a copper cent that has lain in vine- 
gar, are valued remedies among the laity. 

In trichophytosis capitis the hair should be cut short for at 
least a half inch all around the affected spot or spots, the scales 
cleaned from the scalp, and the diseased hairs extracted by 
means of a properly constructed epilation forceps. The para- 
siticide, preferably a bi-chlorid of mercury solution, one to 
three grains to the ounce, or an ointment of the oleate of cop- 
per, a half drachm to one drachm to the ounce should be im- 
mediately applied, and well rubbed in twice a day. 

Electric cataphoresis may be employed with good results, 
using a one per cent, bi-chlorid of mercury solution in connec- 
tion with the anode. 



T-^rrz. 



TRICHOPHTTOSIS {RINGWORM). 801 

Epilation should be repeated weekly, and local treatment 
continued as long as necessary. The strictest attention should 
be given to cleanliness, and all bonnets, hats, caps or other 
head-gear, as also hair-brushes, combs, etc., that have been pre- 
viously used, should be destroyed. In schools and public insti- 
tutions the separation of affected individuals and of their cloth- 
ing, should be rigidly enforced, in order to prevent the further 
spread of the disease. 

The most important internal remedies are sepia and tellu- 
rium. Others occasionally of service are : arsenicum^ alb.y cal- 
carea curb., and sulphur. 
D. C— 51 



CHAPTER X. 

SCABIES (itch). 

Definition. — Scabies is a contagious disease of the skin caused 
by an animal parasite called the acarus scabiei. The disease is 
characterized by the formation of vesicles and pustules situated 
on inflamed bases, and also by the intense nightly aggravation 
of the itching. 

Scabies, though common in Great Britain and on the Conti- 
nent, is a comparatively rare disease in this country, constitut- 
ing, in my experience, only about two per cent, in private 
practice. 

As soon as the acari have alighted on the skin, they immedi- 
ately proceed to burrow, the male going only deep enough to 
secrete himself under the scales of the superficial stratum, while 
the female constructs a long, tortuous canal or cuniculus in 
which she deposits her eggs as she advances. After she has 
finished laying her eggs, she remains at the end of her cunicu- 
lus, where, in a few weeks, she dies, unless removed or killed 
by treatment sooner. 

On the tenth day, the ova are hatched, and as soon as the 
young acari mature, they seek the surface, where the young 
females become impregnated, and they in turn begin burrowing 
and laying eggs as they advance. These canals or cuniculi are 
in appearance much like a needle scratch, and have at one end 
a fine, white, glistening point, which can be easily removed 
with a fine needle, and these points, placed under a microscope, 
prove to be the female acari. The male acarus never burrows, 
and is very rarely detected. The female acari, by burrowing, 
produce the itching; and being more active at night than dur- 
ing the day, give rise to the nightly aggravation. The inflam- 
mation, vesicles and pustules are caused by the scratching. 

Etiology. — Scabies is the most contagious of all the skin dis- 
eases. It requires no particular susceptibility of the cuticle to 
its influence, but may be transmitted by direct contact with 
the disease, by sleeping in bed with an infected person, or by 
wearing the clothing previously worn by a diseased subject. 

It is mainly a filth disease, and is much more common among 
the poor and those who are careless of their personal cleanli- 
ness, than among the better classes. In the poorer classes, 
(802) 



SCABIES {ITCH). 803 

where cleanliness is almost entirely neglected, and the people 
live in crowded and poorly-ventilated houses, the means of 
communication are particularly numerous, and it is among these 
classes that the majority of cases of scabies occur. 

The principal etiological factor of the disease is the acarus 
scabiei. This parasite, or evidences of its being present, is 
found in every case of scabies, and its cuniculus is one of the 
diagnostic symptoms of the disease. The acarus is shaped 
much like a turtle. The neck is long and can be elongated or 
retracted ; and the head is provided with two jaws. A full- 
grown acarus has four pairs of legs, two anterior and two pos- 
terior ; the anterior pairs being articulated and armed with 
suckers, while the posterior pairs are covered with hairs. On 
the back are numerous fine spines or projections pointing up- 
ward and posteriorly, which effectually prevent the creature's 
retrogressing. The young acari have but six legs. 

Symptomatology. — The period of incubation of this disease 
varies according to the degree of healthfulness of the child, 
and lasts from two to five days. In healthy children the erup- 
tion usually appears about two days after the exposure, while 
in sickly and poorly-nourished infants it does not appear for 
four or even five days. 

The first noticeable symptom is a more or less redness of the 
skin of the part exposed. This redness is soon followed by a 
true inflammation and with the formation of minute pearly ves- 
icles, and accompanied by intolerable itching. Frequent scratch- 
ings rupture these vesicles and their contents are exuded over 
the skin. This fluid is highly contagious, and being carried to 
the surrounding surface, sets up a new inflammation with ves- 
icles, and in this way is the disease extensively and rapidly 
spread. 

The vesicles when first appearing are minute points filled 
with a colorless fluid, which soon becomes opaque, and in scrof- 
ulous subjects, rapidly changes to pus and forms pustules. The 
number of vesicles varies ; in some cases they are very numerous, 
while in others they are scarce. They are generally isolated, 
irregular in size, are somewhat elevated above the surrounding 
skin, and are sometimes intermixed with the eruptions of inter- 
trigo, psoriasis and lichen. They frequently are ruptured spon- 
taneously, but more often by scratching ; and from their exuded 
contents small thin scabs are formed. Sometimes the scratch- 
ing is so severe as to cause bleeding, and when such is the case, 
the scabs are thick and black. There is a particular preference 
shown by the scari for the thin portions of the skin, such as is 
between the fingers and toes, covering the ano-genital region, 
on the inner aspect of the thighs and arms, and on the backs 



804 THE DISEASES OF CHILDREX. 

of the hands and feet. As it is communicated by contact from 
one child or person to another, the first symptoms will be no- 
ticed on the part so exposed ; and this site varies with the age 
of the children. In infants, the thighs and buttocks, from the 
frequency with which they are handled, are usually the starting 
point ; while in older children and those old enough to wear 
long night clothes, the wrists, fingers and ankles suffer the on- 
set, and from these sites it is quickly spread by scratching and 
friction. 

The intense nightly itching sets up various irritations in the 
affected child, principal among which are sleeplessness and di- 
gestive disturbances, with their long train of sympathetic 
symptoms ; but these generally disappear very quickly when 
the cause has been removed. As before stated, scabies is very 
amenable to treatment, but from improper food, lack of cleanli- 
ness, careless treatment, etc., the disease may continue indefi- 
nitely, setting up symptoms which eventually become chronic, 
leaving the system in a condition susceptible to the attacks of 
various diseases, and which, from the weakened condition, may 
rapidly carry the little one to the grave. 

Diagnosis. — As the acarus is the cause of this disease, then, 
naturally, the presence of this parasite, its burrow, or other evi- 
dences of its presence, will be the diagnostic symptoms, but fre- 
quently, from the scratch marks, these characteristics cannot be 
detected, and from its resemblance to various other skin dis- 
eases, the diagnosis is exceedingly difficult. 

According to Kippax, the following symptoms, where they 
can be found, will be sufficient to differentiate scabies from the 
other eruptions which it may resemble : 

" I. The presence of cuniculi with their contained acari. 

^'2. The seat of the eruption, which is mostly in the interdig- 
its and wrists, and in the flexures of the body, the buttocks 
and the dorsal surface of the penis. Scabies seldom appears 
above the nipple line. 

"3. The multiformity of the eruption. 

'* 4. The itching, which, though continuing during the day, 
is characteristically worse at night. 

*' 5. The evidence of contagion in the household, other mem- 
bers of the family being affected. 

"6. The rapid disappearance of the symptoms under parasiti- 
cidal treatment." 

Prognosis. — Scabies, in itself, is a mild disease and has no 
severe constitutional symptoms, and through an improper di- 
agnosis it may be prolonged for years, but when correctly diag- 
nosed the prognosis is always good, as it yields so readily to 
treatment. 



SCABIES {ITCH). 805 

Treatment. — As the disease is of parasitical origin, the best 
treatment would be that which would destroy these parasites 
the quickest, and do the least harm to the patient. According 
to M. Gras, who has experimented for years with the acarus, 
it is killed 

When immersed in vinegar in 20 minutes. 
When immersed in alcohol in 20 minutes. 
When immersed in turpentine in 9 minutes. 
When immersed in potass, iod. in 4-6 minutes. 

It will be seen from the above table that turpentine and pot- 
ash are particularly destructive to this pest and hence their 
use in the treatment will be followed by prompt results. Be- 
sides these two remedies, sulphur also stands high as an anti- 
parasiticide. These substances are to be used in the form of 
an unguent, care being taken to vary their strength according 
to the extent of surface over which they are to be spread. 

Before applying, the child is to have a warm bath, and a 
thorough scrubbing with soap in order to remove all possible 
dirt, scabs, scales and other debris, and soften the skin. Then 
apply the ointment, wrap the child up well and put it to bed. 
In the morning another bath should be given, and at night 
again a third bath and another rubbing with the ointment. 
Two or three applications are usually sufificient to effect a cure. 
They should be kept up until all itching has ceased. All the 
clothing and bedding used by the patient should be carefully 
sterilized or fumigated before they are used again. 

The sulphur may be used as strong as 100 grains to the 
ounce of vaselin for children over five years, while younger 
children should have from 60 grains dowm. The turpentine 15 
to 20 drops, decreasing the strength for youth and extent of 
surface, while the potash is to vary from 5 to 20 grains per 
ounce. A solution of i per cent, carbolic acid or bi-chlorid of 
mercury I-5000, is very effective, being highly destructive to 
the acarus and harmless to the patient. The bi-chlorid should 
not be used too freely in the very young. In small children 
balsam of Peru will prove an efficient application. 



INDEX 



*'A. B.C." Cereal food. 58. 

Abscess of ear, 123. 

Abscess in nursing, mammary, 36. 

Abscess, retro-pharjngeal, 532. 

Accidents of birth, 36. 

Adenitis, 642 ; definition, 642 ; eti- 
ology, 642 ; treatment, 645. 

Albuminuria, 426. 

Alcohol, use of, in infants, 21. 

American -Swiss food, 59. 

Amygdalitis. See Tonsilitis. 

Anatomical, peculiarities of infants, 
20. 

Anemia in nursing, 36. 

Angina, cause of ear trouble, 122, 

Apex beating, 16. 

Aphthae, 157. 

Appearance of nurse, 42. 

Arteries in infancy, 5. 

Artificial food, 40. 

Asphyxia at birth, 27; causes, 27; 
diagnosis, 27; treatment, 27; Dr. 
Parker on, 28. 

Asthenia at birth, 26; treatment, 26. 

Asthma, 577. 

Astigmatism, 106. 

Atelectasis, 583. 

Ataxy, hereditary, 710. 

Ataxy, locomotor, acquired, 712. 

Atropine, use of, in infancy, 21. 

Attitude in disease, 12. 

Auditory canal at birth, 116. 

Auditory nerve, destruction of, effects 
of on internal ear, 139. 

Aural remedies, 141. 

Auscultation, 15 ; mode of, in chil- 
dren, 16. 

B 

Baby, dressing of, 67. 

Bath, daily, 69; directions for, 70; 
time for, 71 ; hot bath, 23; in col- 
lapse, 23; diarrhea, 23; in shock, 
23; in vomiting, 23; Bright's dis- 
ease, 23; constipation, 23. 



Bathing, the cause, ear disease, 122. 

Beck, Dr. J. B., on narcotics, 20. 

Bed for baby, description of, 73. 

Bernard, Dr. Claude, on pathology 
of dyspepsia, 177. 

Billiard, Dr., on gastritis, 166. 

Births, accidents and diseases imme- 
diately following, 26. 

Blair's wheat food, 58. 

Blepharitis, 94. 

Blood, in infancy, 5. 

Blows, effects of on internal ear, 147; 
on eyes, iii. 

Bones, in infancy, 3. 

Boxing the ears, 121. 

Brain, diseases in ear trouble, 122 ; 
in infancy, 4 ; development of, 4 ; 
tumors of, 147. 

Breasts of wet-nurse, 42. 

Bright's disease, 439; bath in, 23. 

Bronchitis, 565 ; capillary, 568. 

Broncho-pneumonia, 552. 

Burns of eye, iii. 



Calculi in urinary passages, 462. 

Cancer, in nursing, 36; of bladder, 
456; of kidneys, 456; treatment, 
medical and surgical, 458. 

Cancrum oris, 161. 

Carbonic acid, in infancy, 6. 

Catarrh, intestinal, 183; gastric, 166; 
of throat in ear disease, 122; mid- 
dle ear, 123. 

Cephalhematoma, 28; effects on ear, 
146. 

Cerebro-spinal fever, 604; Dr. J. 
Lewis Smith on, 604; in relation to 
eye diseases, 109. 

Chalazion, 99. 

Charcot's sclerosis, 677. 

Charles on 24 hrs. urine, 420. 

Cheadle, Dr., formula for humanized 
milk, 49. 

Cheyne- Stokes breathing, 6. 

Chicken-pox (see Varicella), 322. 

(807) 



808 



INDEX. 



Childhood, period of, i. 

Children, auscultation of, 15; height 
of, 8; examination of sick, 13; pal- 
pation of, 16; percussion of, 17; 
weight of, table of, 8. 

Cholera infantum, IQ3; diagnosis, 195; 
mortality in, 184; nature of, 193; 
symptoms, 193 ; treatment of, 196; 
Dr. N. F. Cooke on, 196. 

Chorea, definition of, 662 ; diagnosis 
of, 668; complications in, 667; pa- 
thology of, 663 ; prognosis in; 668 ; 
Dr. Sam'l Worcester on, 663; symp- 
toms of, 665 ; treatment of, 668. 

Churchill, Dr., on bread jelly, 56. 

Ciliaris, acute, 94. 

Circulation, in infancy, 5; Holden 
on, 5. 

Coates, Dr., on gangrene of mouth, 
164. 

Cod-liver oil, in dyspepsia, 178; in- 
unctions of, 22. 

Colic, article on, 204; causes, 204; 
symptoms, 205 ; treatment of, 206. 

Collapse, hot bath in, 23; of lung, 583. 

Coloboma, 76. 

Complexion, in disease, 11. 

Congenital, disease of heart, 387; dys- 
pepsia, 171; ptosis, 76. 

Congestion of brain, 735; symptoms, 
736; treatment, 738. 

Conjunctivitis, catarrhal, 82; chapter 
on, 82; treatment of, 82; phlyctenu- 
lar, 83 ; Dr. Leibold on, 85. 

Constipation, chapter on, 200; pathol- 
ogy of, 203 ; treatment of, 202. 

Consumption, in nursing, 36. 

Continued fever, 615. 

Convalescence in chronic maladies, 
10. 

Convergent strabismus, 102. 

Convulsions, 652 ; etiology of, 652 ; 
diagnosis, 654; prognosis, 654; sig- 
nificance of, 9 ; sudden death from, 
11; symptoms, 653; treatment of, 

655. 

Corectopia, 77. 

Cornea, opacities of, 93 ; treatment 
of 94 ; staphj-loma of, 94 ; ulcers of, 
86. 

Corj'za, chapter on, 515; symptoms 
of, 516; treatment of, 517. 

Cough, 511 ; as symptom, 511 ; treat- 
ment, 512; remedies in, 512-514. 

Craniotabes, 240. 

Cross-eye, 102. 

Croup, false, 534; spasmodic, 534; 
true, 538. 

Croupous pneumonia, 552. 



Cry, in disease, 12. 

Cutaneous vs. auditory, impressions, 

118. 
Cuts, of eye, iii. 
Cyanosis, 388; treatment, 389. 



D 



Daily News Sanitarium, 187. 

Daily bath in infancv, 69. 

Dake, Dr. J. P., on ''' Similars," 19. 

Death, sudden, from collapse of lung, 
11; from convulsions, 11. 

Dentition, a cause of ear disease, 122; 
effects of upon ears, 148; first, 222; 
order of eruption during, 223; pre- 
mature decay of teeth during, 225 ; 
second, 226; treatment of, 226; gum 
lancet in difficult, 228; Dr. J. W. 
White on, 232; indications for lanc- 
ing, 230. 

Destruction of auditory nerve, 139. 

Development of bones in infancy, 4; 
development of brain in infancy, 4; 
development of ear in infancy, 138; 
development of jaws, 4; develop- 
ment of teeth, 4. 

Diabetes, insipidus, 489; symptoms of, 
490; urine in, 490; treatment of, 492; 
mellitus, 470; analysis of urine in, 
475 ; complications of, 472; diabetic 
coma, 473 ; Stern on, 470 ; Schnee 
on, 470; Kiihl on, 470; pathology 
of, 471 ; sex in, 471 ; reports of cases, 
481; symptoms, 472; treatment of, 
477 ; table of diet, 478 ; electricity 
in, 479. 

Diarrhea, chapter on, 179; compara- 
tive mortality from, 184; varieties of, 
180; complications, 186; symptoms 
of, 186; treatment of, 188. 

Diathetic diseases, chapter on, 233. 

DiflTuse keratitis, 91; diffuse nephritis^ 

439- 

Digestive organs, diseases of, 152. 

Diphtheria, chapter on, 336; cause of 
death in, 351; complications, 360; 
etiology, 339 ; contagiousness of, 
342; Klebs-Loffler bacillus, 344; 
Sevestre on, 349; Dr. S. Danforth 
o"' 3371 ^^- W* G* Douglas on, 
337; Dr. Kearsley on, 338; Sir M. 
McKenzie on, 336; immunity from, 
350; laryngeal, 358; diagnosis, 358; 
symptoms of, 356-359; treatment of, 
361; intubation in, 368; Dr. J. S. 
Mitchell on, 364; Dr. E. M. Hale 
on, 366; Dr. R. Hughes on, 364; 
tracheotomy in, 368. 



'f .. 4J 



INDEX. 



809 



Disease, signs of, ii; attitude in, 12; 
complexion in, 11; cry in, 12; facial 
lines in, 12 ; Dr. Eustace Smith on, 
12. 

Diseases, systemic and general, 108. 

Diseases, non-eruptive, contagious, 

336- 
Diseases, lachrymal, 99; treatment of, 

100. 
Disorders of sleep, 729; disorders of 

urinary tract, 420. 
Dressing the baby, directions for, 70; 

dressing the navel, 67. 
Drum membrane, examination of, 

117; malformations of, 116. 
Dysentery, 197; diagnosis of, 198; 

symptoms, 198; treatment, 198. 
Dyspepsia, congenital, 171; diagnosis, 

176; treatment, 177. 



Ear, diseases of the, 115; malforma- 
tion of, 115; auricle, 115; external 
auditory canal, 1 16; middle ear, 1 16; 
examination of, 117; care of the,i2o; 
causes of disease of, 1 2 1 ; significance 
of in brain diseases, 122; diseases of 
external, 123. 

Ear, internal, 137; imperfect develop- 
ment of, 138; diagnosis of diseases 
in, 138; effectof destruction of audi- 
tory canal, 139; treatment of, 140; 
foreign bodiesin, 145; injuries of, 150; 
removal of foreign bodies from, 150. 

Ectopia tarsi, 76. 

Eczema,757; etiology of, 785; varieties, 
760; symptoms, 761 ; pathology of, 
764; treatment of, 764. 

Eczema of external ear, 123. 

Electricity as a galactagogue, 39. 

Emetics, danger of, in infants, 20. 

Emphysema, 580; symptoms of, 581 ; 
treatment of, 582. 

Enteric fever, 615. 

Enuresis, 494 ; reflex, 495 ; diurnal, 
496; examination of patient with, 
497; treatment of, 497 ; miscellane- 
ous notes on, 499; cases of, 500. 

Entropion, 76. 

Endocarditis, 401 ; phj'sical signs of; 
402; treatment of, 403. 

Entero-colitis, 183. 

Enteralagia, 204. 

Epilepsy, 659 ; symptoms, 657 ; treat- 
ment of, 658. 

Epistaxis, 519; treatment of, 520. 

Epidemic meningitis, 604. 

Epicanthus, 76. 



Erythema, 777; symptoms of, 778; di- 
agnosis, 779 ; treatment, 779. 

Eruptive fevers, the, 272. 

Erysipelas, 784; diagnosis of, 787; 
symptoms, 786; treatment of, 788. 

Esophagitis, 165; J. Lewis Smith on, 
165; treatment of, 165. 

Eyes, diseases of the, in infants, 74; 
malformations of, 76; vascular 
nerve, 77; examination of the, 78. 



False croup, 534. (See Spasmodic 
Laryngitis.) 

Farinaceous foods, 58. 

Febrile diarrhea, 183. 

Feeding, artificial, 46 ; with cow's 
milk, 46: boiled milk, 50 ; human- 
ized milk, 49; peptonized milk, 48 ; 
sterilized milk, 52; "proteinol," 52; 
Dr. G. W. Winterburn's food, 52. 

Feeding, forced, see Gavage, 61; re- 
capitulation of, 64. 

Fetal condition of lung, 583; fetal cir- 
culation, 385. 

Fevers, eruptive, 272. 

First toilet, baby's, 67. 

Flour, wheat, how prepared, 56. 

Focal sclerosis, 677. 

Follicular stomatitis, 157. (See Stom- 
atitis.) 

Fontanels, closure of anterior, 3 ; pos- 
terior, 3. 

Foods and feeding, 32; commercial, 
the, 57; cereal foods and their uses, 

53- 

Food, artificial, with nursing baby, 
44; farinaceous, 58; Liebig, 59; 
milk, 59; barley water, 54; bread 
jelly, 56 ; Meigs and Pepper's for- 
mula, 56; oats, 54; wheat, 54; wheat 
flour, prepared, 56; best test for a 
babj^ 33 ; solid, in nursing, 45. (See 
Feeding.) 

Foreign bodies in ear, 150; foreign 
bodies in eye, 11 1. 

Fremitus, vocal, 16. 

French measles (see Rotheln), 284. 

Frequency of nursing, 43. 

Fruits, eating of, by nursing women, 
40. 



Gangrene of mouth, 161 ; pathologj^ 
162; symptoms, 162; prognosis, 163; 
treatment, 164; Dr. Coates on, 164; 
M. Taupin on, 164. 

Gastric catarrh (see Gastritis), 166. 



810 



INDEX 



Gastritis, i66; causes of, i66; compli- 
cations of, 167 ; treatment of, 168 ; 
Jahr on, 169; Pepper on, 170. 

Gelatin in dyspepsia, 178. 

General diseases, consideration of, 
604. 

Gerber's food, analysis of, 59. 

German measles (see Rotheln), 284. 

Gertrude suit, the, 67. 

Glasses, the use of, 105; selection of, 
107. 

Glioma of the retina, 107 ; diagnosis, 
113 ; treatment, 114. 

Growth of infants, 7. 



Holland, Sir Henry, on dyspepsia, 
176. 

Hubbell's wheat food, analysis of, 58. 

Hydronephrosis, 459; treatment "of, 
459- 

Hj'drocephalus, 750; acquired, 752; 
congenital, 751; symptoms, 752; 
prognosis, 754; treatment, 755. 

Hysteria, 721 ; symptoms, 723; diag- 
nosis, 725; treatment, 726. 

Hypertrophy of tonsils (see Tonsilitis, 
chronic), 529. 



H 

Harelip, 35. 

Hawley's food, analysis of, 59. 

Headache in children, 733 ; treatment 

of. 734- 

Heart, affections of the, 383 ; method 
of study, 384 ; fetal circulation, 385 ; 
Leavitt on, 385; Keating on, 386; 
congenital disease of, 387; diagnosis 
of, 388; valvular disease of heart, 
390; Dr. E. A. Neatly on, 390; 
symptoms of valvular disease, 393; 
tricuspid, 392 ; aortic insufficiency, 
393; Corrigan on, 393; complica- 
tions of, 394; treatment of, 395; en- 
docarditis, 401 ; pericarditis, 405; 
myocarditis, 409; general consider- 
ations for remedies, 410. 

Hearing in infancy, 118; auditory 
center, 119; sound vs. motion, 120. 

Height of children, table of, 8. 

Hematuria, 451; differential diagnosis 
of, 451. 

Hemorrhage, cerebral, 679; symp- 
toms, 680; diagnosis, 681; prog- 
nosis, 682 ; treatment, 683. 

Hemorrhage, spinal, 700; treatment, 
701. 

Hemorrhage, umbilical, 29; symp- 
toms, 30; treatment, 31. 

Herpes zoster, 781. (See Zoster.) 

Hints, nursing, 66. 

Hints, therapeutic, 19 

Hives (see Urtacaria), 793; symptoms, 
794; treatment, 795. 

Heterophoria, 104 ; etiology of, 105 ; 
treatment, 105. 

Hordeolum, 98; etiology, 99; treat- 
ment, 99. 

Hot bath, 23. 

Holden on infantile circulation, 5. 

Houghton, H. C, on aural remedies, 
141. 



Idiocy, 713; diagnosis of, 714; treat- 
ment of, 715. 

Impetigo contagiosa, 790. 

Imperfect development of ear, 138. 

Incontinence of urine, 494. 

Infancy, anatomical peculiarities of, 
2; weight in, 3; nervous system in, 
3; glandular system in, 4; circula- 
tion in, 5; hearing in, 118; use of 
alcohol in, 21 ; anodynes in, 22. 

Infantile remittent fever (see Ty- 
phoid), 615. 

Infantile paralysis, 696. 

Infantile sj'philis, 269. 

Infantile tetanus, 672. 

Inflammation of stomach, 166. 

Inflammation of tonsils, 524. 

Inflammation of middle ear, 124. 

Inflammatory diarrhea, 183. 

Injuries of ear, 150. 

Injuries of eye, no. 

Insanitj"^, 718; diagnosis and prog- 
nosis, 720; symptoms, 719. 

Insects in ear, 150. 

Interstitial keratitis, 91. 

Intestinal catarrh, 183. 

Intestinal obstruction, 218. 

Intestinal parasites, 207 ; symptoms 
of, 211; treatment of, 212; ascarides 
lumbricoides, 213; oxj^uris vermi- 
culosis, 208 ; tenia, 209. 

Intussusception, 218; pathology, 219; 
prognosis, 220; symptoms of, 219; 
treatment of, 220. 

Itch (see Scabies), 802. 



Jacobi, Dr., on feeding, 34. 
Jahr, on gastritis, 169. 
Jelly, bread, 56. 
Juice, raw-meat, 60. 



T-sr 



INDEX. 



811 



K 

Keasbey and Mattison's food, analy- 
sis of, 59. 

Keratitis, diffuse, 91; diagnosis, 91; 
symptoms, 91; prognosis, 92; treat- 
ment, 92; marginal, 87. 

Kidney, scrofulous, 460 ; tuberculosis 
of, 459; Kiihl on, 470. 



Laceration of eye, iii. 

Lachrymal disease, 99. 

Larrabee, Dr. J. A., on diabetes, 470. 

Laryngismus stridulus, 536; treat- 
ment, 537. 

Laryngitis, acute membranous, 538; 
season, 539; pathology of, 545; J. S. 
Mitchell on, 541; complications of, 
544; prognosis, 547; diagnosis, 546; 
treatment of, 548; chronic, 535; 
sj'mptoms, 535. 

Laryngitis, spasmodic, 534; diagnosis, 
535 ; treatment, 535. 

Leibig's foods, analysis of, 59. 

Leibold, Dr., on conjunctivitis, 85. 

Lines, facial, 12. 

Liver in infancy, 4; situation of, 4; 
weight of, 4. 

Lobar pneumonia, 552 ; lobular pneu- 
monia, 552. 

Lockjaw (see Tetanus), 672. 

Lung fever (see Pneumonitis), 552. 

Luxatio lentis congenitalis, 77. 

Lymphatics, in infancy, 4. 

M 

Malformation of eye, 76. 

Malignant meningitis, 604. 

Marasmus, pathology of, 10. 

Mastoid disease, 10. 

Mastoid process at birth, 117. 

McClellan on thymus, 4. 

Measles, 276; eruption in, 277; vari- 
eties, 278; complications, 279; 
symptoms, 276; diagnosis, 280; 
prognosis, 281 ; sequela, 280 ; mor- 
tality, table of, 283; treatment, 282. 

Measles, French, 284; German, 284. 

Meat juice, raw, 60. 

Meat preparations, 60. 

Meigs and Pepper's formula, 56. 

MelHn's food, analysis of, 59. 

Meningitis, 741 ; effects of on ears, 
147 ; pathology, 742 ; prognosis in, 
743 \ symptoms, 742 ; treatment, 
748; tubercular, 744; symptoms of, 
745; diagnosis, 746; treatment, 748. 



Menstruation, effect of on nursing, 

137- 

Mercury, effect of in infanc}"^, 20. 

Milk, asses', 51 ; cow's, analysis of, 50; 
boiled, 50; foods, analysis of, 59; 
goats', 51 ; human, 51 ; humanized, 
49; Cheadle on, 49; peptonized, 48; 
scantiness of in anemia, 38; steril- 
ized, 53. 

Morbilli (see Measles), 276. 

Mouth, gangrene of, 161. 

Muguet (see Thrush), 159. 

Mumps, 380. 

Murdock's food, analysis of, 59. 

Murmurs, cardiac, 16; respiratory, 15. 

Myelitis, 693 ; treatment, 694 ; an- 
terior polyomyelitis, 696; cause of, 
697 ; diagnosis, 698; treatment, 699; 
chronic, 695; treatment of, 696. 

Myocarditis, 409; treatment of, 410. 

Mj'opia, requiring glasses, 106. 

N 

Nasal catarrh (see Coryza), 515. 

Navel, dressing of the, 67. 

Nephritis, acute, 439; complications, 
446; urine in, 448 ; diarrhea in, 448; 
course of, 442; prognosis, 443; 
symptoms, 439; treatment of, 443 ; 
sub-acute, 448; analysis of urine in, 
450; duration of, 448; patholog}^ 
449; treatment, 449. 

Nettle rash (see Hives), 793. 

Nervous system, affections of, 647 ; 
general remarks on diagnosis of, 
648.^ 

Nestle's food, analysis of, 59. 

Night terrors, 731; symptoms and 
treatment, 731. 

Nipple, retracted, 36. 

Noma (see Gangrene of Mouth), i6r. 

Non-eruptive contagious diseases, 336. 

Nurse, wet, selection of, 41. 

Nursing, directions for, 43 ; diseases 
contraindicating, 35; effect of men- 
struation on, 37; effect of preg- 
nancy on, 37 ; rickets as a result of, 

38. 
Nutrolactis, analysis of, 59; effect of, 

59- 

o 

Oats as a baby food, 54. 

Opacitus of cornea, 93. 

Ophthalmia neonatorum, 78; cause of, 
79; symptoms of, 79; prognosis and 
treatment of, 81; phlyctenular, 87; 
tarsi, 94. 



812 



INDEX. 



Opium, effect of on infants, 20. 
Orthophoria, 104. 
Osseous system, in infancy, 20. 
Otitis media, acute, 124. 
Oxyuris vermiculosis, 208. 



Paralysis, 675 ; diagnosis, 676; prog- 
nosis, 677; cerebro-spinal, multiple, 
677 ; diagnosis and prognosis, 678; 
treatment, 679; spinal, 690; treat- 
ment, 691 ; pseudo - hypertrophic, 
702; prognosis and treatment, 703; 
of the portio dura, 703; prognosis 
and treatment, 705. 

Pack, wet sheet, use of, 24. 

Paraphlegia, spastic, 701. 

Parasites, intestinal, 207. 

Parolitis, 380. 

Parotiditis, 380; symptoms of, 381 ; 
diagnosis of, 382 ; treatment of, 382. 

Parrot, on 24-hours' urine of infants, 
420. 

Palate, cleft, 35. 

Pericarditis, 405 ; pathology of, 406; 
prognosis in, 407. 

Pertussis (see Whooping Cough), 371. 

Phthisis, pulmonary, 588 ; pathology, 
589; complications, 590; treatment, 

591- 

Pleuris}--, 595; symptoms, 596; physi- 
cal signs, 598; diagnosis, 600; prog- 
nosis and treatment, 601. 

Pneumonitis, 552 ; patholog}^ 553; 
clinical history, 556; physical signs, 
557; diagnosis, 559; prognosis, 560; 
treatment, 562. 

Polycoria, 77. 

Porrigo, contagiosa, 790; treatment, 
791. 

Pott's disease, 693; treatment, 693. 

Psoriasis, 771 ; pathology, 772; treat- 
ment, 773. 

Ptosis, congenital, 76. 

Pupillary membrane, persistent, 77. 

Pyuria, 451; differential diagnosis of, 
452. 

Pseudo-membranous laryngitis, 538. 

Q 

Quinsy (see Tonsilitis), 524. 

R 

Rachitis, 235; causes, 236; pathologj' 
of, 238 ; first stage, 238 ; second 
stage, 240; third stage, 242 ; symp- 
toms, 243; complications, 245; 
treatment, 246. 



Respiratory organs, diseases of, 508. 

Respiration in infancy, abdominal, 3; 
Cheyne-Stokes, 6; puerile, 16; apex, 
16. 

Red-gum (see Strophulus), 775. 

Retro-pharyngeal abscess, 532 ; treat- 
ment, 533. 

Rheumatism, 63S; symptoms, 639; 
treatment, 640. 

Ridge's food, analysis of, 58. 

Ringworm, 79S ; treatment, 800. 

Robinson's patent barley, 58. 

Roseola, 317; symptoms, 318; diag- 
nosis, 319; differential table of, 320; 
treatment, 319. 

Rotheln, 284; duration of, 285; symp- 
toms, 285; diagnosis, 286; differ- 
ential table of, 320; treatment, 288. 

Rubella (see Rotheln), 284. 

Rubella (see Measles), 276. 

s 

Savory and Moore's food, analysis of» 

59- 

Scabies (see Itch), 802; treatment of> 
805. 

Scarlet fever, 289; regular, 290; irreg- 
ular, 294; malignant, 296; compli- 
cations, 297; symptoms, 298; diag- 
nosis, 300; differential table of, 320; 
duration of, 301 ; mortalitj'^ from, 
302; prophylaxis, 303; treatment, 

305- 

Sclerosis, primary lateral, 701; treat- 
ment, 701. 

Sclerosis, multiple cerebro-spinal (see 
Paralysis), 677. 

Scrofula, 257 ; pathologj', 258 ; diag- 
nosis and symptoms, 259; treat- 
ment, 261. 

Sleep, disorders of, 729; causes of dis- 
turbed, 730; treatment, 730. 

Sprue (see Stomatitis, Thrush), 159. 

Stomach, inflammation of (see Gas- 
tritis), 166. 

Stomatitis, chapter on, 153 ; simple or 
catarrhal, 153; symptoms, 154; ul- 
cerous, 155; treatment, 156; folli- 
cular (apthas), 157; symptoms, 158; 
treatment, 159; thrush, 159; symp- 
toms, 160; treatment, 161; gangre- 
nous, 161. 

Strabismus, 102; treatment, 103. 

Suit, the Gertrude, 67. 

St. Vitus' dance (see Chorea), 662, 

Strophulus, 775; diagnosis, 776; treat- 
ment, 776. 

Syphilis, infantile, 267; symptoms, 
268 ; treatment, 270. 



TNDEX. 



813 



Tabes mesenterica (see Tuberculosis), 

253- 

Tetanus, infantile, 672 ; symptoms, 
673 ; treatment, 674. 

Typhoid fever, infantile, 615; symp- 
toms, 617; pathologj', 619; diag- 
nosis, 620; treatment, 621. 

Tonsilitis, 524; etiology of, 525; symp- 
toms, 526; course, 528; treatment, 

529- 
Tonsilitis, chronic, 529 ; etiology, 530 ; 

symptoms, 531; treatment, 531, 
Trichophytosis (see Ringworm), 798; 

treatment of, 800. 
Trismus nascentium (see Tetanus), 

672. 
Tuberculosis, acute, 250; etiology of, 

251; symptoms of, 252; treatment 

of, 253; tabes mesenterica, 253; 

symptoms of, 254; treatment, 255. 
Tumors, cerebral, 684; varieties, 685 ; 

localization of, 686; treatment of, 

689. 
Tussis convulsiva (see Whooping 

Cough), 371. 



u 



Ulcers of cornea (see Cornea), 86; 

phlyctenular, 87 ; treatment, 88. 
Urea of infants and children, 423 ; 

quantity in 24 hours, 423, 



Urine, the, of infancy and childhood, 
420; clinical notes on, 421; reaction, 
422 ; of the new born, 433. 

Urine, the, in various disorders of 
childhood, 435 ; fevers, 435; typhoid 
fever, 435; whooping cough, 436; 
measles, 437. 

Uricemia, 464; urine in, 467; treat- 
ment, 467. 

Urticaria (see Hives), 793; symptoms, 
794; treatment, 795. 



Vaccinia, 328 ; Dr. W. T. Plant on, 

329- 

Vaccination, 330; methods of, 331; 
painless, 331; symptoms and course, 
332; complications, 333; after-treat- 
ment of, 334. 

Varicella, 322 ; diagnosis, 323; treat- 
ment, 328. 

w 

Weaning, indications for, 38. 

Wet nurse, selection of, 41. 

Weight of infants at birth, 8. 

Whooping cough, 371 ; symptoms, 
371; complications, 374; diagnosis, 
371^ ; mortality in, 376; treatment, 
376. 

z 

Zoster, 781; symptoms, 782; treat- 
ment, 783. 



3477 
Z300 












'"■^^ ^ 



^ -n^ V 









%-^v^.~' „v^"~ ■*- 



/. '' '' N ^ sV 



?- ^% 



\..^^ * 



» ,■%' -%• 






-^y.. O 






a; '^ ^ 



..^^•^o' 






X . V- 



.4^ 



•■^-b. 



•0^ 



v^-^ ^'^^ ' 



.V 






v^^ -^i^. 






^^ .^ 




.^ , N C 









'^r 



.^0^ 










^' .0* 



V" 



<.'^* 



. s^ .A 






"^^l^^ 






,-^ ^^;^, 



.^% 



v^"^ •^*. 






V^^ 



.,<t 



•i^-^ 



,*-V>i#-%'' .^.*'' 



s^' 












V^' v^^-^^''^ ^^ 



.^v?^ 



:%. 



-*^ 






^.s- 



'-^'', •■" 




<>• v^ 


-f^^\./^ 


^0O^ 



V -^ 



ov 






-;*o'-*^ 



% 



s^^ 



,0- 



^. S' 



■ V -^ 









^, 













